Healthcare Provider Details

I. General information

NPI: 1902355365
Provider Name (Legal Business Name): MATTHEW NERVINO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2016
Last Update Date: 09/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12910 TOTEM LAKE BLVD NE STE 105
KIRKLAND WA
98034-2901
US

IV. Provider business mailing address

10832 FORBES CREEK DR U306
KIRKLAND WA
98033-3817
US

V. Phone/Fax

Practice location:
  • Phone: 425-823-8631
  • Fax:
Mailing address:
  • Phone: 831-383-8311
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number60669897
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: