Provider Demographics
NPI:1710915996
Name:LEE, MATTHEW D (PA)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:D
Last Name:LEE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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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:803-296-7330
Practice Address - Street 1:9 RICHLAND MEDICAL PARK DR STE 505
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6844
Practice Address - Country:US
Practice Address - Phone:803-434-2505
Practice Address - Fax:803-434-2181
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105544363A00000X
TN1368363A00000X
SC2350363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2277PAMedicaid
SC2277PAMedicaid