Healthcare Provider Details

I. General information

NPI: 1538191879
Provider Name (Legal Business Name): MATTHEW JOHN MCKENNA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 07/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3102 N CROATAN HWY
KILL DEVIL HILLS NC
27948-9200
US

IV. Provider business mailing address

3102 N CROATAN HWY
KILL DEVIL HILLS NC
27948-9200
US

V. Phone/Fax

Practice location:
  • Phone: 252-261-9940
  • Fax: 252-261-9087
Mailing address:
  • Phone: 252-261-9940
  • Fax: 252-261-9087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number200500680
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: