Healthcare Provider Details

I. General information

NPI: 1346227170
Provider Name (Legal Business Name): JOSE MATA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 11/17/2025
Certification Date: 11/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14841 179TH AVE SE STE 210
MONROE WA
98272-1127
US

IV. Provider business mailing address

14841 179TH AVE SE STE 210
MONROE WA
98272-1127
US

V. Phone/Fax

Practice location:
  • Phone: 360-217-1155
  • Fax: 360-217-1154
Mailing address:
  • Phone: 360-217-1155
  • Fax: 360-217-1154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00046741
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: