Basic Information
| Provider Information | |||||||||
| NPI: | 1396302592 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SHENAS | ||||||||
| FirstName: | MATINE | ||||||||
| MiddleName: | JALAL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 525 LILLY RD NE | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985065101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604937230 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 525 LILLY RD NE | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985065101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604937230 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2019 | ||||||||
| LastUpdateDate: | 11/10/2019 | ||||||||
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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 | 207Q00000X | ML60955451 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.