Provider Demographics
NPI:1801243779
Name:ROY, MATHEW
Entity type:Individual
Prefix:
First Name:MATHEW
Middle Name:
Last Name:ROY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2175 E SOUTHLAKE BLVD
Mailing Address - Street 2:STE 120
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092-6544
Mailing Address - Country:US
Mailing Address - Phone:817-813-2700
Mailing Address - Fax:
Practice Address - Street 1:1920 E STATE HIGHWAY 114
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092-6510
Practice Address - Country:US
Practice Address - Phone:817-442-5698
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-19
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP130598363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily