Healthcare Provider Details

I. General information

NPI: 1932799418
Provider Name (Legal Business Name): MATTHEW JAMES GRIFFIN ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2021
Last Update Date: 07/19/2024
Certification Date: 07/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18TH MEDICAL GROUP UNIT 5142
APO AP
96368-5142
US

IV. Provider business mailing address

18TH MEDICAL GROUP UNIT 5142
APO AP
96368-5142
US

V. Phone/Fax

Practice location:
  • Phone: 315-630-4780
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT003075
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL6590
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: