Provider Demographics
NPI:1053898833
Name:SPORTSMEDICINE OUTREACH SPECIALIST
Entity type:Organization
Organization Name:SPORTSMEDICINE OUTREACH SPECIALIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:OVERLIN
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:602-689-9588
Mailing Address - Street 1:835 W WARNER RD
Mailing Address - Street 2:STE 101-448
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85233-7269
Mailing Address - Country:US
Mailing Address - Phone:480-980-8206
Mailing Address - Fax:480-281-5224
Practice Address - Street 1:835 W WARNER RD
Practice Address - Street 2:STE 101-448
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85233-7269
Practice Address - Country:US
Practice Address - Phone:602-689-9588
Practice Address - Fax:480-281-5224
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-24
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3233363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty