Healthcare Provider Details

I. General information

NPI: 1821850223
Provider Name (Legal Business Name): MICHELLE KATHLEEN MATSUMOTO PT, DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2024
Last Update Date: 01/30/2024
Certification Date: 01/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 HARPER DR NE STE 110
ALBUQUERQUE NM
87109-3540
US

IV. Provider business mailing address

5700 HARPER DR NE STE 110
ALBUQUERQUE NM
87109-3540
US

V. Phone/Fax

Practice location:
  • Phone: 505-823-9166
  • Fax:
Mailing address:
  • Phone: 505-823-9166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License Number4031
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: