Provider Demographics
NPI:1124117700
Name:NOTHERN, MATTHEW ROLAND (NP PAC)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ROLAND
Last Name:NOTHERN
Suffix:
Gender:M
Credentials:NP PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 E HILL STREET
Mailing Address - Street 2:
Mailing Address - City:SIGNAL HILL
Mailing Address - State:CA
Mailing Address - Zip Code:90755-3682
Mailing Address - Country:US
Mailing Address - Phone:562-424-6200
Mailing Address - Fax:562-427-4634
Practice Address - Street 1:3200 LONG BEACH BOULEVARD
Practice Address - Street 2:
Practice Address - City:LONG BECH
Practice Address - State:CA
Practice Address - Zip Code:90806-5062
Practice Address - Country:US
Practice Address - Phone:562-981-6865
Practice Address - Fax:562-595-6471
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2010-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA16544363A00000X
CA13855363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WPA16544BMedicare ID - Type Unspecified
WNP13855BMedicare ID - Type Unspecified
Q26233Medicare UPIN