Provider Demographics
NPI:1407210180
Name:MCDERMOTT, MATHEW (ATC)
Entity Type:Individual
Prefix:
First Name:MATHEW
Middle Name:
Last Name:MCDERMOTT
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 UTE AVE
Mailing Address - Street 2:
Mailing Address - City:AZTEC
Mailing Address - State:NM
Mailing Address - Zip Code:87410-2232
Mailing Address - Country:US
Mailing Address - Phone:505-793-0028
Mailing Address - Fax:
Practice Address - Street 1:500 E CHACO ST
Practice Address - Street 2:
Practice Address - City:AZTEC
Practice Address - State:NM
Practice Address - Zip Code:87410-2170
Practice Address - Country:US
Practice Address - Phone:505-334-9414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-08
Last Update Date:2016-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6062255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer