Provider Demographics
NPI:1225672793
Name:WOLF, MATTHEW
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:WOLF
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2314 SASSAFRAS STREET
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16502-2721
Mailing Address - Country:US
Mailing Address - Phone:814-452-5043
Mailing Address - Fax:814-452-7005
Practice Address - Street 1:145 W 23RD ST STE 101
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16502-2858
Practice Address - Country:US
Practice Address - Phone:814-454-1142
Practice Address - Fax:814-454-1255
Is Sole Proprietor?:No
Enumeration Date:2019-10-29
Last Update Date:2024-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA061256363A00000X
PAOA006404363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant