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General NPI Number Information
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NPI Number | 1053898833
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Entity Type | Organization
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Legal Business Name | SPORTSMEDICINE OUTREACH SPECIALIST
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Dates
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Enumeration Date | 07/24/2018
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Last Update Date | 10/30/2024
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Provider Practice Location Address
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Address Line | 835 W WARNER RD STE 101-448
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City | GILBERT
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State | AZ
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Zip | 85233-7269
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Country | US
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Telephone | 602-689-9588
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Fax | 480-281-5224
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Provider Business Mailing Address
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Address Line | 835 W WARNER RD STE 101-448
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City | GILBERT
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State | AZ
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Zip | 85233-7269
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Country | US
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Telephone | 480-980-8206
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Fax | 480-281-5224
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Authorized Official
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Title or Position | PHYSICIAN ASSISTANT
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Name | MR. MATTHEW DEAN OVERLIN
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Credential | PA-C
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Telephone | 602-689-9588
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 3233
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License Number State | AZ
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