Provider Demographics
NPI:1417793423
Name:MATTHEWS, NICOLENA MARIE
Entity type:Individual
Prefix:
First Name:NICOLENA
Middle Name:MARIE
Last Name:MATTHEWS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:429 NEWELL RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTE CITY
Mailing Address - State:PA
Mailing Address - Zip Code:15438-1157
Mailing Address - Country:US
Mailing Address - Phone:724-317-8941
Mailing Address - Fax:
Practice Address - Street 1:429 NEWELL RD
Practice Address - Street 2:
Practice Address - City:FAYETTE CITY
Practice Address - State:PA
Practice Address - Zip Code:15438-1157
Practice Address - Country:US
Practice Address - Phone:724-317-8941
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-08
Last Update Date:2025-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA065618363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant