Basic Information
| Provider Information | |||||||||
| NPI: | 1568974822 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATSON | ||||||||
| FirstName: | CODY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2003 KOOTENAI HEALTH WAY | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838146051 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086254888 | ||||||||
| FaxNumber: | 2086255734 | ||||||||
| Practice Location | |||||||||
| Address1: | 2199 W IRONWOOD CENTER DR | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838142639 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086254888 | ||||||||
| FaxNumber: | 2086255734 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2017 | ||||||||
| LastUpdateDate: | 06/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | NP67131 | ID | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 363LP0808X | AP60967912 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | G140540 | IA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363L00000X | NP67131 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.