Provider Demographics
NPI:1699108431
Name:KINKADE, MATTHEW C (DPT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:C
Last Name:KINKADE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1177 QUAIL CT STE 200
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-3768
Mailing Address - Country:US
Mailing Address - Phone:262-695-3057
Mailing Address - Fax:262-695-3063
Practice Address - Street 1:1177 QUAIL CT STE 200
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-3768
Practice Address - Country:US
Practice Address - Phone:262-695-3057
Practice Address - Fax:262-695-3063
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-15
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI12324-24225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400171181Medicare PIN