Basic Information
| Provider Information | |||||||||
| NPI: | 1518330323 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MATTHEWS | ||||||||
| FirstName: | KELSEY | ||||||||
| MiddleName: | MARIAH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BUNNER | ||||||||
| OtherFirstName: | KELSEY | ||||||||
| OtherMiddleName: | MARIAH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1 INDEPENDENCE PT STE 212 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296154536 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647976308 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3551A RUTHERFORD RD | ||||||||
| Address2: | |||||||||
| City: | TAYLORS | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29687 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8645224750 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/03/2015 | ||||||||
| LastUpdateDate: | 08/22/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2883 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 2602 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 2736PA | 05 | SC | MEDICAID |