Healthcare Provider Details

I. General information

NPI: 1871179747
Provider Name (Legal Business Name): MATTHEW EMERSON JOHNSON HA61109811
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/22/2021
Last Update Date: 03/22/2021
Certification Date: 03/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10413 BEARDSLEE BLVD
BOTHELL WA
98011-3463
US

IV. Provider business mailing address

22055 129TH PL SE
KENT WA
98031-3937
US

V. Phone/Fax

Practice location:
  • Phone: 425-485-6403
  • Fax:
Mailing address:
  • Phone: 206-427-2604
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberHA61109811
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: