Individual
MARK R. MATTICE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
NP
Contact information
Practice address
MEDICAL CENTER BLVD, WINSTON SALEM, NC 27157-0001
(336) 716-2255
Mailing address
PO BOX 344, WINSTON SALEM, NC 27102-0344
(336) 716-2255
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
200883
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
194975
MEDCOST
—
05
—
7004065
—
NC
01
—
7046747
AETNA
—
Enumeration date
01/19/2006
Last updated
08/16/2012
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