Provider Demographics
NPI:1275856353
Name:WAFFENSMITH, MATTHEW G (PTA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:G
Last Name:WAFFENSMITH
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15335 WOODLAND BEACH RD
Mailing Address - Street 2:
Mailing Address - City:DEERWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:56444-8607
Mailing Address - Country:US
Mailing Address - Phone:218-851-0213
Mailing Address - Fax:
Practice Address - Street 1:15335 WOODLAND BEACH RD
Practice Address - Street 2:
Practice Address - City:DEERWOOD
Practice Address - State:MN
Practice Address - Zip Code:56444-8607
Practice Address - Country:US
Practice Address - Phone:218-851-0213
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-03
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNA1243225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant