Provider Demographics
NPI:1154725562
Name:LADNER, MATTHEW JAMES (LPTA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JAMES
Last Name:LADNER
Suffix:
Gender:M
Credentials:LPTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15190 COMMUNITY RD
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-3485
Mailing Address - Country:US
Mailing Address - Phone:228-831-0416
Mailing Address - Fax:228-831-0521
Practice Address - Street 1:15190 COMMUNITY RD
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3485
Practice Address - Country:US
Practice Address - Phone:228-831-0416
Practice Address - Fax:228-831-0521
Is Sole Proprietor?:No
Enumeration Date:2014-10-14
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPTA5207225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant