Provider Demographics
NPI:1568635795
Name:PRESTON, MATTHEW JON (PTA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JON
Last Name:PRESTON
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 1:658 PARK STREET
Mailing Address - Street 2:
Mailing Address - City:UNION CENTER
Mailing Address - State:WI
Mailing Address - Zip Code:53962
Mailing Address - Country:US
Mailing Address - Phone:608-547-3810
Mailing Address - Fax:
Practice Address - Street 1:658 PARK STREET
Practice Address - Street 2:
Practice Address - City:UNION C ENTER
Practice Address - State:WI
Practice Address - Zip Code:53962
Practice Address - Country:US
Practice Address - Phone:608-547-3810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-09
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1399-019225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant