Provider Demographics
NPI:1346383536
Name:SHADE, MATTHEW DAVID (MED, ATC)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:DAVID
Last Name:SHADE
Suffix:
Gender:M
Credentials:MED, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:365 N FIELDSTONE CT
Mailing Address - Street 2:
Mailing Address - City:YARDLEY
Mailing Address - State:PA
Mailing Address - Zip Code:19067-5709
Mailing Address - Country:US
Mailing Address - Phone:215-595-7132
Mailing Address - Fax:
Practice Address - Street 1:365 N FIELDSTONE CT
Practice Address - Street 2:
Practice Address - City:YARDLEY
Practice Address - State:PA
Practice Address - Zip Code:19067-5709
Practice Address - Country:US
Practice Address - Phone:215-595-7132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0040812255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer