Provider Demographics
NPI:1588644546
Name:MATTOCKS, LARRY WAYNE JR (PT)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:WAYNE
Last Name:MATTOCKS
Suffix:JR
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1599 N HERMITAGE RD
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:PA
Mailing Address - Zip Code:16148-3180
Mailing Address - Country:US
Mailing Address - Phone:724-962-7920
Mailing Address - Fax:724-962-6029
Practice Address - Street 1:1599 NORTH HERMITAGE RD
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:PA
Practice Address - Zip Code:16148
Practice Address - Country:US
Practice Address - Phone:724-962-7920
Practice Address - Fax:724-962-6029
Is Sole Proprietor?:No
Enumeration Date:2006-01-18
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT007303L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1016368810002Medicaid
PA104392OtherUPMC
PA220033OtherHEALTH AMERICA/HEALTH ASSURANCE
PA5160144OtherAETNA
PA548783OtherHIGHMARK GROUP
PA724159OtherHEALTH AMERICA/HEALTH ASSURANCE
PA025221OtherMEDICARE GROUP
PA1983093OtherHIGHMARK GROUP
PA118111OtherMEDICARE GROUP
PA417718OtherHIGHMARK
PA579COtherUPMC
PA548783OtherHIGHMARK GROUP
PA023572M45Medicare PIN