Healthcare Provider Details

I. General information

NPI: 1659995579
Provider Name (Legal Business Name): MATTHEW GIBSON MARVELL NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2020
Last Update Date: 09/03/2024
Certification Date: 08/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 FAYETTEVILLE ST
DURHAM NC
27707-2325
US

IV. Provider business mailing address

71 PROSPECT AVE STE 110
HUDSON NY
12534-2928
US

V. Phone/Fax

Practice location:
  • Phone: 919-956-4000
  • Fax:
Mailing address:
  • Phone: 518-828-3327
  • Fax: 518-828-2532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number351306
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: