Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | 18542 | SC |
NPI | 1003244450 |
---|---|
Provider Name | Matthew Keaton |
First Address | Greenville, SC 29601-2842 |
Second Address | Greenville, SC 29607-3415 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/10/2013 |
Last Update Date | 09/06/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
NP2749 | (05) | SC |