Provider Demographics
NPI:1053367326
Name:WREN, MATTHEW PETER (MS, PT)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:PETER
Last Name:WREN
Suffix:
Gender:M
Credentials:MS, PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2296 JOHN ROLFE PKWY
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23233-3548
Mailing Address - Country:US
Mailing Address - Phone:804-741-7077
Mailing Address - Fax:804-741-0377
Practice Address - Street 1:2296 JOHN ROLFE PKWY
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23233-3548
Practice Address - Country:US
Practice Address - Phone:804-741-7077
Practice Address - Fax:804-741-0377
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305003703225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
00V001P68Medicare ID - Type Unspecified