Provider Demographics
NPI:1437654597
Name:WANDER, MATTHEW BRYAN (ATC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:BRYAN
Last Name:WANDER
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 1:5 LONGVIEW DR
Mailing Address - Street 2:
Mailing Address - City:AVELLA
Mailing Address - State:PA
Mailing Address - Zip Code:15312-2756
Mailing Address - Country:US
Mailing Address - Phone:412-999-2922
Mailing Address - Fax:
Practice Address - Street 1:122 OAK VIEW CIR
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32082-2645
Practice Address - Country:US
Practice Address - Phone:412-999-2922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-29
Last Update Date:2019-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer