Provider Demographics
NPI:1316460256
Name:HALL, ROBERT-MATTHEW (NP)
Entity type:Individual
Prefix:
First Name:ROBERT-MATTHEW
Middle Name:
Last Name:HALL
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10131 VICTOR DR
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-3379
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9075 SANDIDGE CENTER CV
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-3514
Practice Address - Country:US
Practice Address - Phone:662-895-4949
Practice Address - Fax:662-893-1103
Is Sole Proprietor?:No
Enumeration Date:2017-07-23
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902176363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily