CMS-1500 Box 24J / 33a • NPI
1891415063
Type 1 Individual Rendering/Ordering
HIPAA NUCC Taxonomy • CMS Code
363AM0700X (CMS 97)
Licensed & Credentialed Physician Assistants & Advanced Practice Nursing Providers — Physician Assistant, Medical
Box 32 Service Location & ZIP+4
607 W MAIN ST, GRANGEVILLE, ID, 83530-1345
✓ 9-Digit EDI 837 ZIP+4 (83530-1345)
✓ HHS OIG LEIE Sanction Screening — VERIFIED CLEAR:
NPI
1891415063 (MATTHEW WADE BLACK, PA) has 0 active federal exclusions across all 84,224 HHS OIG LEIE sanction records (Database Verified: 2026-11-11).
CMS Medicare Order & Referring PECOS Eligibility
Medicare Part B
✓ Eligible
DMEPOS Ordering
✓ Eligible
Home Health (HHA)
✓ Eligible
Power Mobility
✓ Eligible
Hospice Referring
No
Empirical CMS Medicare Claims, CPT Utilization & Part D Prescribing (NPI #1891415063)
Actual Top Prescribed Medications (CMS Part D)
| Brand / Generic Medication | Total Claims | Patients |
|---|---|---|
| Amoxicillin-Clavulanate Potass Amoxicillin/Potassium Clav | 32 | 29 |
| Atorvastatin Calcium Atorvastatin Calcium | 11 | <11 |
| Azithromycin Azithromycin | 17 | 17 |
| Cephalexin Cephalexin | 12 | 11 |
| Cyclobenzaprine Hcl Cyclobenzaprine Hcl | 15 | 15 |
| Fluconazole Fluconazole | 13 | 11 |
| Nitrofurantoin Mono-Macro Nitrofurantoin Monohyd/M-Cryst | 27 | 23 |
| Ondansetron Odt Ondansetron | 13 | 12 |
Official CMS NPPES Credential & Practice Profile
| 10-Digit NPI Number | 1891415063 (NPI-1 Individual Practitioner) |
|---|---|
| Provider / Legal Name | MATTHEW WADE BLACK, PA |
| Plain-English Specialty | Licensed & Credentialed Physician Assistants & Advanced Practice Nursing Providers — Physician Assistant, Medical NUCC Code: 363AM0700X (Physician Assistant, Medical) |
| Certifying / Licensing Body | State Medical / Healthcare Licensing Board & National Specialty Board |
| Practice Location Address | 607 W MAIN ST, GRANGEVILLE, ID, 83530-1345 |
| Practice Telephone / Fax | Tel: (208) 983-1700 | Fax: (208) 983-4665 |
| Administrative Mailing Address | 607 W MAIN ST, GRANGEVILLE, ID, 83530-1345 |
| Enumeration & Last Sync | Enumerated: 2022-08-29 | CMS Record Updated: 2023-10-25 |
Clinic Location, Accessibility & Directions
📍 Practice Location & Patient Access
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Plain-English Taxonomy & CMS Crosswalk (363AM0700X)
What Does Taxonomy Code 363AM0700X Mean?
In the HIPAA National Uniform Claim Committee (NUCC) classification, code 363AM0700X translates to:
"Licensed & Credentialed Physician Assistants & Advanced Practice Nursing Providers — Physician Assistant, Medical"
Specialty Clinical Procedures & Therapeutic Classes
Standard Scope of Care (MATTHEW WADE BLACK, PA)
Typical CPT / Diagnostic Procedures:- Comprehensive Outpatient & Inpatient Clinical Evaluation (CPT 99202–99215)
- Diagnostic Workup, Laboratory Ordering & Evidence-Based Care Coordination
- Preventive Screening, Patient Counseling & Multidisciplinary Referral
- Evidence-Based Specialty Pharmacotherapy & Preventive Regimens (CMS Part D Standard)
All Registered NUCC Taxonomies & State Licenses
| Taxonomy Code & Plain-English Description | State License & Primary Status |
|---|---|
363AM0700X — Physician Assistant, MedicalPlain English: Licensed & Credentialed Physician Assistants & Advanced Practice Nursing Providers — Physician Assistant, Medical | State: ID | License: PA-2620 | Primary: Yes (Primary) |
Medical Billing, RCM & Hospital Credentialing Teams:
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