Provider Demographics
NPI:1730391764
Name:WOLLASTON, MATTHEW THOMAS (PT)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:THOMAS
Last Name:WOLLASTON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1450 TREAT BLVD # 300
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94597-2168
Mailing Address - Country:US
Mailing Address - Phone:925-952-2888
Mailing Address - Fax:
Practice Address - Street 1:3128 SANTA RITA RD
Practice Address - Street 2:STE A
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94566-8300
Practice Address - Country:US
Practice Address - Phone:925-350-4742
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2019-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT259552251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT259550Medicare PIN