Provider Demographics
NPI:1316044266
Name:MATARESE, MICHELLE M (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:M
Last Name:MATARESE
Suffix:
Gender:F
Credentials:PA-C
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:704-316-5100
Mailing Address - Fax:704-316-5101
Practice Address - Street 1:200 S HERLONG AVE STE B
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1182
Practice Address - Country:US
Practice Address - Phone:803-324-1950
Practice Address - Fax:803-324-1933
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2019-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL2930363A00000X
NC0010-01206363AS0400X
MA1463363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1316044266Medicaid
NC1316044266Medicaid