Basic Information
| Provider Information | |||||||||
| NPI: | 1205096773 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ATENCIO | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | STEPHEN | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3858 PENNSYLVANIA ST APT 55 | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986325236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602814748 | ||||||||
| FaxNumber: | 3606363421 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | LONGVIEW | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986323229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604238800 | ||||||||
| FaxNumber: | 3606363421 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2008 | ||||||||
| LastUpdateDate: | 06/09/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 8310 | OR | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.