Provider Demographics
NPI:1700130978
Name:POWER, MATTHEW TIMOTHY (PA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:TIMOTHY
Last Name:POWER
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 848932
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-8932
Mailing Address - Country:US
Mailing Address - Phone:803-296-9200
Mailing Address - Fax:803-296-9697
Practice Address - Street 1:104 SALUDA POINTE DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-7295
Practice Address - Country:US
Practice Address - Phone:803-296-9200
Practice Address - Fax:803-296-9697
Is Sole Proprietor?:No
Enumeration Date:2012-11-09
Last Update Date:2015-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSC0699E878Medicare PIN