Healthcare Provider Details

I. General information

NPI: 1871487165
Provider Name (Legal Business Name): MATTHEW BROWN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/03/2025
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

119 KENNINGHALL CT SE
SMYRNA GA
30082-3891
US

IV. Provider business mailing address

119 KENNINGHALL CT SE
SMYRNA GA
30082-3891
US

V. Phone/Fax

Practice location:
  • Phone: 646-812-4838
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN335463
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number819385
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAPRN-6176
License Number StateHI
# 5
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN-130277
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: