Provider Demographics
NPI:1255853305
Name:BOELTER, MATTHEW L (HCP)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:L
Last Name:BOELTER
Suffix:
Gender:M
Credentials:HCP
Other - Prefix:MR
Other - First Name:MATTHEW
Other - Middle Name:L
Other - Last Name:BOELTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:HCP
Mailing Address - Street 1:11451 OREGON AVE N
Mailing Address - Street 2:
Mailing Address - City:CHAMPLIN
Mailing Address - State:MN
Mailing Address - Zip Code:55316
Mailing Address - Country:US
Mailing Address - Phone:727-242-4711
Mailing Address - Fax:
Practice Address - Street 1:11451 OREGON AVE N
Practice Address - Street 2:
Practice Address - City:CHAMPLIN
Practice Address - State:MN
Practice Address - Zip Code:55316
Practice Address - Country:US
Practice Address - Phone:727-242-4711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-11
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2808237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist