Provider Demographics
NPI:1619537834
Name:TERRY, MATTHEW LEE (APRN-CNP)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:LEE
Last Name:TERRY
Suffix:
Gender:M
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 COURTHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:PRINCETON
Mailing Address - State:WV
Mailing Address - Zip Code:24740-2431
Mailing Address - Country:US
Mailing Address - Phone:304-425-3922
Mailing Address - Fax:304-487-0229
Practice Address - Street 1:365 COURTHOUSE RD
Practice Address - Street 2:
Practice Address - City:PRINCETON
Practice Address - State:WV
Practice Address - Zip Code:24740-2431
Practice Address - Country:US
Practice Address - Phone:304-425-3922
Practice Address - Fax:304-487-0229
Is Sole Proprietor?:No
Enumeration Date:2019-06-19
Last Update Date:2019-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV103773363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV103773OtherLICENSE