Basic Information
| Provider Information | |||||||||
| NPI: | 1306165600 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOWARD | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | CHARLES | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4601 PARK RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282093239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043232000 | ||||||||
| FaxNumber: | 7049457681 | ||||||||
| Practice Location | |||||||||
| Address1: | 950 STATE FARM RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | BOONE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286075021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043232000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/26/2010 | ||||||||
| LastUpdateDate: | 11/07/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010-04453 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1306165600 | 05 | NC | MEDICAID | 0010-04453 | 01 | NC | STATE LICENSE | OTHER |