MEDICARE: MATTHEW ALAN PENIX CNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	APRN.CNP.0033330	OH

General Provider Information

NPI Number	:	1487352076
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MATTHEW ALAN PENIX CNP

Provider Business Mailing Address
First Line	:	1735 27TH ST STE B06
Second Line	:
City	:	PORTSMOUTH
State	:	OH
Zip	:	45662-2681
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	812 MOHAWK DR
Second Line	:
City	:	MC DERMOTT
State	:	OH
Zip	:	45652-9000
Country	:	US
Telephone Number	:	740-356-6030
Fax Number	:	740-356-6033

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/22/2023
Last Update Date	:	10/30/2023

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