Provider Demographics
NPI:1548479017
Name:MATTHEWS, NICHOLAS GRANT (PT)
Entity type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:GRANT
Last Name:MATTHEWS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:MR
Other - First Name:NICK
Other - Middle Name:GRANT
Other - Last Name:MATTHEWS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PT
Mailing Address - Street 1:2803 WAUNONA WAY
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53713-1528
Mailing Address - Country:US
Mailing Address - Phone:608-222-7951
Mailing Address - Fax:
Practice Address - Street 1:110 BELMONT RD
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53714-3129
Practice Address - Country:US
Practice Address - Phone:608-249-7391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3294-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40173700Medicaid