Provider Demographics
NPI:1629538236
Name:DORSEY, MATT PAUL (MACOM, LAC)
Entity Type:Individual
Prefix:
First Name:MATT
Middle Name:PAUL
Last Name:DORSEY
Suffix:
Gender:M
Credentials:MACOM, LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11250 TAYLOR DRAPER LN APT 524
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-2437
Mailing Address - Country:US
Mailing Address - Phone:512-925-5489
Mailing Address - Fax:
Practice Address - Street 1:11250 TAYLOR DRAPER LN APT 524
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-2437
Practice Address - Country:US
Practice Address - Phone:512-925-5489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAC01551171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist