Provider Demographics
NPI:1942552773
Name:DOLES, MATTHEW JASON (ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:JASON
Last Name:DOLES
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2317 KENT ST
Mailing Address - Street 2:
Mailing Address - City:BRYAN
Mailing Address - State:TX
Mailing Address - Zip Code:77802-1936
Mailing Address - Country:US
Mailing Address - Phone:979-575-1506
Mailing Address - Fax:979-458-1055
Practice Address - Street 1:2317 KENT ST
Practice Address - Street 2:
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-1936
Practice Address - Country:US
Practice Address - Phone:979-575-1506
Practice Address - Fax:979-458-1055
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-03
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT25402255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer