Provider Demographics
NPI:1417688714
Name:GREENE, MATTHEW CLAYTON (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:CLAYTON
Last Name:GREENE
Suffix:
Gender:M
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 1:7207 WALTERBORO RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28227-1243
Mailing Address - Country:US
Mailing Address - Phone:330-697-3509
Mailing Address - Fax:
Practice Address - Street 1:220 N CAMDEN RD
Practice Address - Street 2:
Practice Address - City:WINGATE
Practice Address - State:NC
Practice Address - Zip Code:28174-9644
Practice Address - Country:US
Practice Address - Phone:704-233-8051
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-19
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC0010-13009363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program