Healthcare Provider Details

I. General information

NPI: 1679810220
Provider Name (Legal Business Name): MATTHEW BRANKLEY BEAM PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2013
Last Update Date: 12/20/2019
Certification Date: 12/20/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1915 RANDOLPH RD
CHARLOTTE NC
28207-1101
US

IV. Provider business mailing address

4601 PARK RD SUITE 300
CHARLOTTE NC
28209-3239
US

V. Phone/Fax

Practice location:
  • Phone: 704-323-3300
  • Fax:
Mailing address:
  • Phone: 704-323-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-04076
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: