Basic Information
Provider Information | |||||||||
NPI: | 1639603509 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VANWINKLE | ||||||||
FirstName: | MATTHEW | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PT, DPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 8750 GREENWOOD AVE N | ||||||||
Address2: | S-1 | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 98103 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2067825789 | ||||||||
FaxNumber: | 2067825794 | ||||||||
Practice Location | |||||||||
Address1: | 3290 NE 65TH STREET | ||||||||
Address2: | UNIT 101 | ||||||||
City: | SEATTLE | ||||||||
State: | WA | ||||||||
PostalCode: | 98115 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2063882549 | ||||||||
FaxNumber: | 2068294352 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/17/2017 | ||||||||
LastUpdateDate: | 09/17/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 077348 | IA | N |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   | 225100000X | PT60860658 | WA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.