=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942846803
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BYRON MATHEWS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/25/2019
-----------------------------------------------------
Last Update Date | 11/25/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10835 35TH AVE
-----------------------------------------------------
City | PLEASANT PRAIRIE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53158-4107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-960-5761
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10835 35TH AVE
-----------------------------------------------------
City | PLEASANT PRAIRIE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53158-4107
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------