Provider Demographics
NPI:1639497027
Name:KERNAN, MATTHEW JAMES (PTA)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:JAMES
Last Name:KERNAN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 N 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:MADILL
Mailing Address - State:OK
Mailing Address - Zip Code:73446-1200
Mailing Address - Country:US
Mailing Address - Phone:580-795-3301
Mailing Address - Fax:580-795-7307
Practice Address - Street 1:16002 LAKE SHORE VILLA DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613
Practice Address - Country:US
Practice Address - Phone:813-968-5093
Practice Address - Fax:813-968-5934
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-10
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL21681225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant