Basic Information
| Provider Information | |||||||||
| NPI: | 1710461652 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ROTHSTROM | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | JONATHON | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19 CASCADE DR | ||||||||
| Address2: | |||||||||
| City: | WALLA WALLA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993622509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095408237 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7320 216TH ST SW STE 320 | ||||||||
| Address2: | |||||||||
| City: | EDMONDS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980268006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256733900 | ||||||||
| FaxNumber: | 4256733910 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2018 | ||||||||
| LastUpdateDate: | 11/05/2018 | ||||||||
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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 | 363AS0400X | 60872146 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 2110750 | 05 | WA | MEDICAID |