Provider Demographics
NPI:1295004356
Name:PROVENZANO, MATTHEW V (PT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:V
Last Name:PROVENZANO
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 1:1790 HAMILL RD
Mailing Address - Street 2:
Mailing Address - City:HIXSON
Mailing Address - State:TN
Mailing Address - Zip Code:37343-4905
Mailing Address - Country:US
Mailing Address - Phone:423-771-4600
Mailing Address - Fax:866-591-0619
Practice Address - Street 1:1790 HAMILL RD
Practice Address - Street 2:
Practice Address - City:HIXSON
Practice Address - State:TN
Practice Address - Zip Code:37343-4905
Practice Address - Country:US
Practice Address - Phone:423-771-4600
Practice Address - Fax:866-591-0619
Is Sole Proprietor?:No
Enumeration Date:2011-12-19
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist