Provider Demographics
NPI:1134636202
Name:MATA, SHANE ANTHONY (PT, DPT)
Entity type:Individual
Prefix:DR
First Name:SHANE
Middle Name:ANTHONY
Last Name:MATA
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 1:600 S LIVINGSTON AVE STE 210
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-5415
Mailing Address - Country:US
Mailing Address - Phone:973-992-0733
Mailing Address - Fax:
Practice Address - Street 1:600 S LIVINGSTON AVE
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-5419
Practice Address - Country:US
Practice Address - Phone:973-992-0733
Practice Address - Fax:973-992-0734
Is Sole Proprietor?:No
Enumeration Date:2018-01-10
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01754500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist