Provider Demographics
NPI:1164714788
Name:MATTINGLY, PATRICIA JANE (MD)
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:JANE
Last Name:MATTINGLY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6324 FAIRVIEW RD STE 390
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-4173
Practice Address - Country:US
Practice Address - Phone:704-316-1120
Practice Address - Fax:704-316-1121
Is Sole Proprietor?:No
Enumeration Date:2011-05-16
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME124636207V00000X
NC2018-01327207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL015209700Medicaid