Healthcare Provider Details

I. General information

NPI: 1801445358
Provider Name (Legal Business Name): BRANDON MATTHEWS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2019
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 OLD MILITARY RD
LAKE PLACID NY
12946-1738
US

IV. Provider business mailing address

6108 SENTINEL RD
LAKE PLACID NY
12946-3645
US

V. Phone/Fax

Practice location:
  • Phone: 518-523-8580
  • Fax:
Mailing address:
  • Phone: 718-916-6617
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: