Healthcare Provider Details

I. General information

NPI: 1104213339
Provider Name (Legal Business Name): MATTHEW LEE ESTES NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2015
Last Update Date: 09/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

148 BILL CARRUTH PKWY STE 220
HIRAM GA
30141
US

IV. Provider business mailing address

148 BILL CARRUTH PKWY STE 220
HIRAM GA
30141-3756
US

V. Phone/Fax

Practice location:
  • Phone: 770-505-0023
  • Fax: 770-505-9003
Mailing address:
  • Phone: 770-505-0023
  • Fax: 770-505-9003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN184263
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN184263
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: