Provider Demographics
NPI:1689155798
Name:FUNG, MATTHEW W (PT, DPT, OCS, CSCS)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:W
Last Name:FUNG
Suffix:
Gender:M
Credentials:PT, DPT, OCS, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 NEW FIDELITY CT
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-2665
Mailing Address - Country:US
Mailing Address - Phone:919-258-2714
Mailing Address - Fax:410-648-4878
Practice Address - Street 1:20 STATE ROUTE 10 W
Practice Address - Street 2:
Practice Address - City:SUCCASUNNA
Practice Address - State:NJ
Practice Address - Zip Code:07876-1724
Practice Address - Country:US
Practice Address - Phone:201-549-5191
Practice Address - Fax:551-361-9176
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305212170225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist