Healthcare Provider Details

I. General information

NPI: 1760503346
Provider Name (Legal Business Name): MATTHEW STONEBERG MS, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4080 W BROADWAY AVE STE 300
ROBBINSDALE MN
55422-5607
US

IV. Provider business mailing address

2907 HILLSBORO AVE N APT 303
NEW HOPE MN
55427-2339
US

V. Phone/Fax

Practice location:
  • Phone: 763-533-0541
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1893
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: