Provider Demographics
NPI:1013946342
Name:MATLOCK, JODY KAYE (MPA-C)
Entity Type:Individual
Prefix:
First Name:JODY
Middle Name:KAYE
Last Name:MATLOCK
Suffix:
Gender:F
Credentials:MPA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1107 REYNOLDS ST
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28112-4351
Mailing Address - Country:US
Mailing Address - Phone:704-289-8220
Mailing Address - Fax:704-289-9195
Practice Address - Street 1:1107 REYNOLDS ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-4351
Practice Address - Country:US
Practice Address - Phone:704-289-8220
Practice Address - Fax:704-289-9195
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103793363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ00991Medicare UPIN
NC2759560Medicare ID - Type Unspecified