Provider Demographics
NPI:1306882543
Name:WARREN, MATTHEW S (PA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:S
Last Name:WARREN
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 1:850 SOUTHAMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23510-1021
Mailing Address - Country:US
Mailing Address - Phone:757-668-9920
Mailing Address - Fax:757-668-9930
Practice Address - Street 1:850 SOUTHAMPTON AVE
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23510-1021
Practice Address - Country:US
Practice Address - Phone:757-668-9920
Practice Address - Fax:757-668-9930
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001919363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010237190Medicaid
VA09081C38Medicare ID - Type Unspecified
VA010237190Medicaid