Provider Demographics
NPI:1457359564
Name:BRANNON, MATTHEW LANE (PTA)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:LANE
Last Name:BRANNON
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 1:1414 PARK ST
Mailing Address - Street 2:
Mailing Address - City:PASO ROBLES
Mailing Address - State:CA
Mailing Address - Zip Code:93446-2160
Mailing Address - Country:US
Mailing Address - Phone:805-237-0272
Mailing Address - Fax:
Practice Address - Street 1:1414 PARK ST
Practice Address - Street 2:
Practice Address - City:PASO ROBLES
Practice Address - State:CA
Practice Address - Zip Code:93446-2160
Practice Address - Country:US
Practice Address - Phone:805-237-0272
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT 4604225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant