Provider Demographics
NPI:1801332788
Name:NELSON, MATTHEW ALEX (LMT, CMA, MFA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:ALEX
Last Name:NELSON
Suffix:
Gender:M
Credentials:LMT, CMA, MFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2441 W MENLO DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-0322
Mailing Address - Country:US
Mailing Address - Phone:208-985-0331
Mailing Address - Fax:
Practice Address - Street 1:760 E WARM SPRINGS AVE
Practice Address - Street 2:STE Z
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6476
Practice Address - Country:US
Practice Address - Phone:208-985-0331
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-16
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMAS-2851225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist