Provider Demographics
NPI:1407614951
Name:MATHISEN, CHRISTOPHER RYAN
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:RYAN
Last Name:MATHISEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:LEHIGHTON
Mailing Address - State:PA
Mailing Address - Zip Code:18235-1305
Mailing Address - Country:US
Mailing Address - Phone:570-778-8239
Mailing Address - Fax:
Practice Address - Street 1:614 INTERCHANGE RD
Practice Address - Street 2:
Practice Address - City:KRESGEVILLE
Practice Address - State:PA
Practice Address - Zip Code:18333-7704
Practice Address - Country:US
Practice Address - Phone:272-639-5350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATE1004075225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant