Provider Demographics
NPI:1346526746
Name:DUPRE, MATTHEW CHRISTOPHER (PTA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:CHRISTOPHER
Last Name:DUPRE
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 1:4017 MARIETTA DR
Mailing Address - Street 2:
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-4030
Mailing Address - Country:US
Mailing Address - Phone:607-221-7940
Mailing Address - Fax:
Practice Address - Street 1:23 WEST GLAN ROAD
Practice Address - Street 2:
Practice Address - City:APALACHIN
Practice Address - State:NY
Practice Address - Zip Code:13732
Practice Address - Country:US
Practice Address - Phone:607-725-0889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-30
Last Update Date:2011-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP82069225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant