Provider Demographics
NPI:1154933810
Name:ANDERSON, MATTHEW DEAN (PA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DEAN
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:313 MAIN ST STE B
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646-2757
Mailing Address - Country:US
Mailing Address - Phone:864-229-4446
Mailing Address - Fax:
Practice Address - Street 1:313 MAIN ST STE A
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-2757
Practice Address - Country:US
Practice Address - Phone:864-229-4446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-23
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3606363A00000X
SCPA3606363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC102029439OtherDRIVERS LICENSE