Basic Information
| Provider Information | |||||||||
| NPI: | 1366435943 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATISTA | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1330 ROCKEFELLER AVE | ||||||||
| Address2: | SUITE 225 | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982011684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252614910 | ||||||||
| FaxNumber: | 4252614911 | ||||||||
| Practice Location | |||||||||
| Address1: | 1330 ROCKEFELLER AVE | ||||||||
| Address2: | SUITE 225 | ||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982011684 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252614910 | ||||||||
| FaxNumber: | 4252614911 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2005 | ||||||||
| LastUpdateDate: | 12/12/2007 | ||||||||
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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 | 363AM0700X | PA10004886 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | PA10004886 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 8435968 | 05 | WA | MEDICAID |