Provider Demographics
NPI:1629662960
Name:PETRISHIN, MATTHEW MICHAEL (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:MICHAEL
Last Name:PETRISHIN
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3321 7TH ST NE APT 313
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58703-1589
Mailing Address - Country:US
Mailing Address - Phone:716-866-8575
Mailing Address - Fax:
Practice Address - Street 1:1 BURDICK EXPY W
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-4406
Practice Address - Country:US
Practice Address - Phone:701-857-5286
Practice Address - Fax:701-857-5694
Is Sole Proprietor?:No
Enumeration Date:2021-02-26
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY046368225100000X
ND2440225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist