Provider Demographics
NPI:1669065785
Name:MARIS, MATTHEW
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:MARIS
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 1:202 W WILSON ST
Mailing Address - Street 2:
Mailing Address - City:WINGATE
Mailing Address - State:NC
Mailing Address - Zip Code:28174-6748
Mailing Address - Country:US
Mailing Address - Phone:801-376-3951
Mailing Address - Fax:
Practice Address - Street 1:13655 PROVIDENCE RD
Practice Address - Street 2:
Practice Address - City:WEDDINGTON
Practice Address - State:NC
Practice Address - Zip Code:28104-9373
Practice Address - Country:US
Practice Address - Phone:704-246-7050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty