Provider Demographics
NPI:1720350234
Name:COLLINS, MATTHEW JOHN (PTA)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:JOHN
Last Name:COLLINS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9089 CLAIREMONT MESA BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1234
Mailing Address - Country:US
Mailing Address - Phone:800-787-6787
Mailing Address - Fax:
Practice Address - Street 1:9089 CLAIREMONT MESA BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1234
Practice Address - Country:US
Practice Address - Phone:800-787-6787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT5179225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant