Provider Demographics
NPI:1437803418
Name:GERVASI, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:GERVASI
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 1:138 LAFAYETTE RD
Mailing Address - Street 2:
Mailing Address - City:AUDUBON
Mailing Address - State:NJ
Mailing Address - Zip Code:08106-1130
Mailing Address - Country:US
Mailing Address - Phone:609-828-8128
Mailing Address - Fax:
Practice Address - Street 1:13447 STAFF SARGENT SIMS ST
Practice Address - Street 2:
Practice Address - City:FORT BLISS
Practice Address - State:TX
Practice Address - Zip Code:79918
Practice Address - Country:US
Practice Address - Phone:609-828-8128
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-08
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer