Healthcare Provider Details

I. General information

NPI: 1407614951
Provider Name (Legal Business Name): CHRISTOPHER RYAN MATHISEN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2024
Last Update Date: 03/11/2024
Certification Date: 03/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

614 INTERCHANGE RD
KRESGEVILLE PA
18333-7704
US

IV. Provider business mailing address

425 N 5TH ST
LEHIGHTON PA
18235-1305
US

V. Phone/Fax

Practice location:
  • Phone: 272-639-5350
  • Fax:
Mailing address:
  • Phone: 570-778-8239
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberTE1004075
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: