Healthcare Provider Details

I. General information

NPI: 1679335913
Provider Name (Legal Business Name): MATTHEW VAUGHN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2024
Last Update Date: 01/23/2024
Certification Date: 01/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6817 SOUTHPOINT PKWY STE 1602
JACKSONVILLE FL
32216-6298
US

IV. Provider business mailing address

6817 SOUTHPOINT PKWY STE 1602
JACKSONVILLE FL
32216-6298
US

V. Phone/Fax

Practice location:
  • Phone: 904-945-7556
  • Fax: 904-379-0113
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA32979
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: