Provider Demographics
NPI:1134273014
Name:SMITH, MATTHEW DONALD (PA-C)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:DONALD
Last Name:SMITH
Suffix:
Gender:M
Credentials:PA-C
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 932
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27331-0932
Mailing Address - Country:US
Mailing Address - Phone:919-776-3750
Mailing Address - Fax:919-776-3760
Practice Address - Street 1:1503 ELM ST
Practice Address - Street 2:SUITE E
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-5666
Practice Address - Country:US
Practice Address - Phone:919-776-3750
Practice Address - Fax:919-776-3760
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-00775363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC69-66199Medicaid
NC0010-00775OtherNC LICENSE
NC69-66199Medicaid