Healthcare Provider Details

I. General information

NPI: 1346699527
Provider Name (Legal Business Name): MATTHEW COOKSEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/08/2016
Last Update Date: 02/19/2021
Certification Date: 02/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2356 CASEY LN
FLEMING ISLAND FL
32003-8771
US

IV. Provider business mailing address

21756 STATE ROAD 54 STE 102
LUTZ FL
33549-2905
US

V. Phone/Fax

Practice location:
  • Phone: 904-657-8485
  • Fax:
Mailing address:
  • Phone: 727-475-5540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL4449
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: