Healthcare Provider Details

I. General information

NPI: 1245748383
Provider Name (Legal Business Name): MATTHEW FREDERICK WYSOCKI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/10/2018
Last Update Date: 01/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5118 BOSWORTH DR
SNOHOMISH WA
98290-7700
US

IV. Provider business mailing address

PO BOX 629
GRANITE FALLS WA
98252-0629
US

V. Phone/Fax

Practice location:
  • Phone: 520-260-3458
  • Fax:
Mailing address:
  • Phone: 520-260-3458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: