Provider Demographics
NPI:1558095414
Name:NORMAN, MATTHEW PAUL
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:PAUL
Last Name:NORMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3709 COACH LANTERN AVE
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-3404
Mailing Address - Country:US
Mailing Address - Phone:919-610-2360
Mailing Address - Fax:
Practice Address - Street 1:1260 N ARENDELL AVE
Practice Address - Street 2:
Practice Address - City:ZEBULON
Practice Address - State:NC
Practice Address - Zip Code:27597-8730
Practice Address - Country:US
Practice Address - Phone:919-235-1965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-14
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC0010-13956363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program