Provider Demographics
NPI:1487982294
Name:SHOULDERS, MATTHEW (KCSA)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:SHOULDERS
Suffix:
Gender:M
Credentials:KCSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 CEDAR WAY
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40601-9003
Mailing Address - Country:US
Mailing Address - Phone:502-454-7766
Mailing Address - Fax:502-454-7788
Practice Address - Street 1:311 CEDAR WAY
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601-9003
Practice Address - Country:US
Practice Address - Phone:502-454-7766
Practice Address - Fax:502-454-7788
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-07
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYSA206246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist