Healthcare Provider Details

I. General information

NPI: 1083324396
Provider Name (Legal Business Name): MIKA MATSUI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2022
Last Update Date: 11/28/2022
Certification Date: 11/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22659 PACIFIC HWY S STE 201
DES MOINES WA
98198-5155
US

IV. Provider business mailing address

22659 PACIFIC HWY S STE 201
DES MOINES WA
98198-5155
US

V. Phone/Fax

Practice location:
  • Phone: 206-824-3668
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberP160460007
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: