Basic Information
| Provider Information | |||||||||
| NPI: | 1023631801 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PEREZ | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | HARRISON | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1959 NE PACIFIC STREET BOX 357115 BOX | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981957115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065982094 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1959 NE PACIFIC ST | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981951918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065982094 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2020 | ||||||||
| LastUpdateDate: | 06/15/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | BP10071460 | TX | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 390200000X | WA | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.