Provider Demographics
NPI:1235758202
Name:KESIC, MATTHEW JOHN (PHD, PA-S2)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOHN
Last Name:KESIC
Suffix:
Gender:M
Credentials:PHD, PA-S2
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2536 HEATHCOTE LN
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-8518
Mailing Address - Country:US
Mailing Address - Phone:919-607-9924
Mailing Address - Fax:
Practice Address - Street 1:217 MAIN STREET
Practice Address - Street 2:
Practice Address - City:BUIES CREEK
Practice Address - State:NC
Practice Address - Zip Code:27506
Practice Address - Country:US
Practice Address - Phone:910-893-1690
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-10
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program