Provider Demographics
NPI:1053787689
Name:MAZARA, MATTHEW SCOTT (PTA)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:SCOTT
Last Name:MAZARA
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10470 DIBERVILLE BLVD
Mailing Address - Street 2:
Mailing Address - City:DIBERVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39540-2419
Mailing Address - Country:US
Mailing Address - Phone:228-280-8120
Mailing Address - Fax:228-280-8121
Practice Address - Street 1:10470 DIBERVILLE BLVD
Practice Address - Street 2:
Practice Address - City:DIBERVILLE
Practice Address - State:MS
Practice Address - Zip Code:39540-2419
Practice Address - Country:US
Practice Address - Phone:228-280-8120
Practice Address - Fax:228-280-8121
Is Sole Proprietor?:No
Enumeration Date:2015-08-18
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS5837225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant