Provider Demographics
NPI:1093787111
Name:SMITH, MATHEW ROOS (PT)
Entity Type:Individual
Prefix:MR
First Name:MATHEW
Middle Name:ROOS
Last Name:SMITH
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10785 W TWAIN AVE STE 223
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89135-3028
Mailing Address - Country:US
Mailing Address - Phone:725-726-7847
Mailing Address - Fax:
Practice Address - Street 1:727 N NELLIS BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89110-5384
Practice Address - Country:US
Practice Address - Phone:725-726-7847
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0329225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV003402627Medicaid
NVV38442OtherMEDICARE PTAN