Healthcare Provider Details

I. General information

NPI: 1063996304
Provider Name (Legal Business Name): MATTHEW VAIL AT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2018
Last Update Date: 07/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 UNIVERSITY AVE W
MINOT ND
58707-0001
US

IV. Provider business mailing address

234 14TH AVE SE APT 310
MINOT ND
58701-5983
US

V. Phone/Fax

Practice location:
  • Phone: 913-271-1739
  • Fax:
Mailing address:
  • Phone: 913-271-1739
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateND
# 3
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number855-19
License Number StateND

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: