Provider Demographics
NPI:1447652540
Name:MATURAN, JAY L (ATC, MAT, LAT)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:L
Last Name:MATURAN
Suffix:
Gender:M
Credentials:ATC, MAT, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:714 EUNICE AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-1917
Mailing Address - Country:US
Mailing Address - Phone:314-359-5019
Mailing Address - Fax:
Practice Address - Street 1:605 E BOONESLICK RD STE 3
Practice Address - Street 2:
Practice Address - City:WARRENTON
Practice Address - State:MO
Practice Address - Zip Code:63383-2127
Practice Address - Country:US
Practice Address - Phone:636-456-6350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-19
Last Update Date:2014-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20140217482251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports