Provider Demographics
NPI:1649706052
Name:KOECKERT, MATTHEW ANTHONY (RN)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ANTHONY
Last Name:KOECKERT
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2080 W ARLINGTON BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-3770
Mailing Address - Country:US
Mailing Address - Phone:252-752-2140
Mailing Address - Fax:252-689-6502
Practice Address - Street 1:2825 RANDOLPH RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1018
Practice Address - Country:US
Practice Address - Phone:704-377-1647
Practice Address - Fax:704-358-8267
Is Sole Proprietor?:No
Enumeration Date:2017-05-04
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV85106390200000X
NC5671367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program