Provider Demographics
NPI:1619119831
Name:BONANDER, MATTHEW ELLIS (DPT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ELLIS
Last Name:BONANDER
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4118 HERDSMAN DR
Mailing Address - Street 2:
Mailing Address - City:KRUM
Mailing Address - State:TX
Mailing Address - Zip Code:76249-1556
Mailing Address - Country:US
Mailing Address - Phone:940-535-8105
Mailing Address - Fax:940-241-4204
Practice Address - Street 1:4118 HERDSMAN DR
Practice Address - Street 2:
Practice Address - City:KRUM
Practice Address - State:TX
Practice Address - Zip Code:76249-1556
Practice Address - Country:US
Practice Address - Phone:940-535-8105
Practice Address - Fax:940-241-4204
Is Sole Proprietor?:No
Enumeration Date:2009-04-02
Last Update Date:2023-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35580225100000X
TX1254357225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABD107Medicare PIN