Provider Demographics
NPI:1346504578
Name:HARRIS, MATTHEW DAVID
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:DAVID
Last Name:HARRIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MATTHEW
Other - Middle Name:DAVID
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPT
Mailing Address - Street 1:96 DOC PERKES LANE
Mailing Address - Street 2:
Mailing Address - City:AFTON
Mailing Address - State:WY
Mailing Address - Zip Code:83110-9621
Mailing Address - Country:US
Mailing Address - Phone:307-885-7878
Mailing Address - Fax:
Practice Address - Street 1:901 ADAMS ST
Practice Address - Street 2:
Practice Address - City:AFTON
Practice Address - State:WY
Practice Address - Zip Code:83110-9621
Practice Address - Country:US
Practice Address - Phone:307-885-5800
Practice Address - Fax:307-885-5865
Is Sole Proprietor?:No
Enumeration Date:2012-07-03
Last Update Date:2013-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-29702251X0800X
WY14722251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic