Provider Demographics
NPI:1629473012
Name:KUNKELMAN, MATTHEW NICHOLAS (PA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:NICHOLAS
Last Name:KUNKELMAN
Suffix:
Gender:M
Credentials:PA
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 1245
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29116-1245
Mailing Address - Country:US
Mailing Address - Phone:803-395-4497
Mailing Address - Fax:803-395-2237
Practice Address - Street 1:187 BUNCH FORD RD
Practice Address - Street 2:
Practice Address - City:HOLLY HILL
Practice Address - State:SC
Practice Address - Zip Code:29059-8224
Practice Address - Country:US
Practice Address - Phone:803-496-3312
Practice Address - Fax:803-496-7713
Is Sole Proprietor?:No
Enumeration Date:2014-10-28
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2209363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPC4116Medicaid
SC423828OtherMEDICARE RHC
SCRHC151Medicaid
SC428926OtherMEDICARE RHC
SCRHC012Medicaid
SC4173OtherMEDICARE PTAN
SCRHC020Medicaid
SCRHC012Medicaid
SCPC4116Medicaid