Provider Demographics
NPI:1922691336
Name:MAGRUDER, MATTHEW ALLEN
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ALLEN
Last Name:MAGRUDER
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 1:11400 N JOG RD
Mailing Address - Street 2:
Mailing Address - City:PALM BEACH GARDENS
Mailing Address - State:FL
Mailing Address - Zip Code:33418-1756
Mailing Address - Country:US
Mailing Address - Phone:561-453-3233
Mailing Address - Fax:
Practice Address - Street 1:1430 66TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-5504
Practice Address - Country:US
Practice Address - Phone:727-343-3019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-17
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS5384237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist