Healthcare Provider Details

I. General information

NPI: 1114463775
Provider Name (Legal Business Name): MATTHEW HUDERLE ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2017
Last Update Date: 05/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 E 1ST ST STE 400
DULUTH MN
55805-2297
US

IV. Provider business mailing address

1000 E 1ST ST STE 400
DULUTH MN
55805-2297
US

V. Phone/Fax

Practice location:
  • Phone: 218-722-5513
  • Fax:
Mailing address:
  • Phone: 218-722-5513
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number3128
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: