Provider Demographics
NPI:1669614699
Name:BRUCKER, MATTHEW PAUL JR (ATC, MED)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:PAUL
Last Name:BRUCKER
Suffix:JR
Gender:M
Credentials:ATC, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 LOG BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:MA
Mailing Address - Zip Code:01949-2252
Mailing Address - Country:US
Mailing Address - Phone:518-222-9049
Mailing Address - Fax:
Practice Address - Street 1:30 LOG BRIDGE RD
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:MA
Practice Address - Zip Code:01949-2252
Practice Address - Country:US
Practice Address - Phone:518-222-9049
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-06
Last Update Date:2009-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA18412255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer