Provider Demographics
NPI:1609334853
Name:WENTZ, MATTHEW BRIAN
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:BRIAN
Last Name:WENTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 NORTHBROOK LN
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:PA
Mailing Address - Zip Code:17361-1256
Mailing Address - Country:US
Mailing Address - Phone:717-891-9310
Mailing Address - Fax:
Practice Address - Street 1:5 NORTHBROOK LN
Practice Address - Street 2:
Practice Address - City:SHREWSBURY
Practice Address - State:PA
Practice Address - Zip Code:17361-1256
Practice Address - Country:US
Practice Address - Phone:717-891-9310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-06
Last Update Date:2020-01-08
Deactivation Date:2019-03-08
Deactivation Code:
Reactivation Date:2020-01-08
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program