Healthcare Provider Details

I. General information

NPI: 1619397569
Provider Name (Legal Business Name): HUSTON JOHNSON MATTSON IV LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2014
Last Update Date: 09/18/2020
Certification Date: 09/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 WEDDINGTON RD
MATTHEWS NC
28104-6267
US

IV. Provider business mailing address

5206 CHELSEY LN
MONROE NC
28110-8618
US

V. Phone/Fax

Practice location:
  • Phone: 704-296-6319
  • Fax:
Mailing address:
  • Phone: 412-979-9047
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberRT004679
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberLAT-2474
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: