Provider Demographics
NPI:1164929857
Name:BIANCUZZO, MATTHEW BRIAN
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:BRIAN
Last Name:BIANCUZZO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2654 W HORIZON RIDGE PKWY # B5-254
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-2803
Mailing Address - Country:US
Mailing Address - Phone:401-489-3394
Mailing Address - Fax:
Practice Address - Street 1:1 TWINS WAY
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-1418
Practice Address - Country:US
Practice Address - Phone:401-489-3394
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV05063102255A2300X
MN30892255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer