Basic Information
| Provider Information | |||||||||
| NPI: | 1619358439 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BEVACQUA | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | ALEXANDER | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 65 E WADSWORTH PARK DR STE 230 | ||||||||
| Address2: | |||||||||
| City: | DRAPER | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840208096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3853088034 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 65 E WADSWORTH PARK DR STE 230 | ||||||||
| Address2: | |||||||||
| City: | DRAPER | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840208096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3853088034 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2015 | ||||||||
| LastUpdateDate: | 03/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 03/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT03402 | RI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT5966 | ME | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 13136 | CT | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 25535 | MA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 047378 | NY | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | J1-0014396 | DE | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 40QA02019100 | NJ | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 5501301792 | MI | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | PT200001236 | DC | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 25503 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.