Provider Demographics
NPI:1043607187
Name:SHAFFER, MATTHEW (LAT ATC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:SHAFFER
Suffix:
Gender:M
Credentials:LAT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:293 RAYMILTON RD
Mailing Address - Street 2:
Mailing Address - City:POLK
Mailing Address - State:PA
Mailing Address - Zip Code:16342-2927
Mailing Address - Country:US
Mailing Address - Phone:814-758-1764
Mailing Address - Fax:
Practice Address - Street 1:293 RAYMILTON RD
Practice Address - Street 2:
Practice Address - City:POLK
Practice Address - State:PA
Practice Address - Zip Code:16342-2927
Practice Address - Country:US
Practice Address - Phone:814-758-1764
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-15
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260023062255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer