Provider Demographics
NPI:1619863594
Name:MATIS, NATHANIEL Q
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:Q
Last Name:MATIS
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 1:930 S 500 E
Mailing Address - Street 2:
Mailing Address - City:HEBER CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84032-4455
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:930 S 500 E
Practice Address - Street 2:
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032-4455
Practice Address - Country:US
Practice Address - Phone:435-649-7640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-16
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT14222693-48102255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer