Provider Demographics
NPI:1417388141
Name:MATZKO, MARY KATHLEEN (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:KATHLEEN
Last Name:MATZKO
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-293-7330
Practice Address - Street 1:14 RICHLAND MEDICAL PARK DR STE 410
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6878
Practice Address - Country:US
Practice Address - Phone:803-434-8740
Practice Address - Fax:803-434-8749
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-05
Last Update Date:2021-09-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC18599363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health