Provider Demographics
NPI:1275034357
Name:O'DONNELL, MATTHEW (FNP-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:O'DONNELL
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6500 CREEDMOOR RD STE 110
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27613-3698
Mailing Address - Country:US
Mailing Address - Phone:919-825-4000
Mailing Address - Fax:
Practice Address - Street 1:6500 CREEDMOOR RD STE 110
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27613-3698
Practice Address - Country:US
Practice Address - Phone:919-825-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-23
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP135855363L00000X
NC5013305363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner