Basic Information
| Provider Information | |||||||||
| NPI: | 1730356858 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITACRE | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | SCOTT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 243511 W HIGHWAY 101 | ||||||||
| Address2: | 250 FORT ST | ||||||||
| City: | PORT ANGELES | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983639472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604526252 | ||||||||
| FaxNumber: | 3604526274 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 FORT ST | ||||||||
| Address2: | |||||||||
| City: | NEAH BAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983570410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606452233 | ||||||||
| FaxNumber: | 3606452305 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/08/2008 | ||||||||
| LastUpdateDate: | 06/07/2016 | ||||||||
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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 | MD60106651 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine | 208D00000X | MD60106651 | WA | N | Allopathic & Osteopathic Physicians | General Practice |
ID Information
| ID | Type | State | Issuer | Description | MD60106651 | 01 | WA | MEDICAL LICENSE | OTHER |