Healthcare Provider Details

I. General information

NPI: 1124117700
Provider Name (Legal Business Name): MATTHEW ROLAND NOTHERN NP PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 08/31/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 LONG BEACH BOULEVARD
LONG BECH CA
90806-5062
US

IV. Provider business mailing address

1600 E HILL STREET
SIGNAL HILL CA
90755-3682
US

V. Phone/Fax

Practice location:
  • Phone: 562-981-6865
  • Fax: 562-595-6471
Mailing address:
  • Phone: 562-424-6200
  • Fax: 562-427-4634

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberA16544
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number13855
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: