Provider Demographics
NPI:1144412362
Name:SMITH, MATTHEW RYAN (ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:RYAN
Last Name:SMITH
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 VONDERBURG DR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-0001
Mailing Address - Country:US
Mailing Address - Phone:813-684-2663
Mailing Address - Fax:813-685-9178
Practice Address - Street 1:615 VONDERBURG DR
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5972
Practice Address - Country:US
Practice Address - Phone:813-684-2663
Practice Address - Fax:813-685-9178
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-12
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107760363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical