Provider Demographics
NPI:1902495369
Name:BRANNON, MATTHEW (MS, LAT, ATC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:BRANNON
Suffix:
Gender:M
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4930 STARBOARD CIR APT 108
Mailing Address - Street 2:
Mailing Address - City:MECHANICSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17050-3242
Mailing Address - Country:US
Mailing Address - Phone:850-419-1400
Mailing Address - Fax:
Practice Address - Street 1:4930 STARBOARD CIR APT 108
Practice Address - Street 2:
Practice Address - City:MECHANICSBURG
Practice Address - State:PA
Practice Address - Zip Code:17050-3242
Practice Address - Country:US
Practice Address - Phone:850-419-1400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-11
Last Update Date:2021-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PART0071232255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
PART007123OtherLICENSE
2000033950OtherBOC