Healthcare Provider Details

I. General information

NPI: 1063342319
Provider Name (Legal Business Name): MATTHEW WARDELL LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MATT WARDELL LAT, ATC

II. Dates (important events)

Enumeration Date: 05/20/2026
Last Update Date: 05/20/2026
Certification Date: 05/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E HANNA AVE
INDIANAPOLIS IN
46227-3630
US

IV. Provider business mailing address

923 N MERIDIAN ST APT 502
INDIANAPOLIS IN
46204-1448
US

V. Phone/Fax

Practice location:
  • Phone: 317-488-0743
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36003941A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: