Healthcare Provider Details

I. General information

NPI: 1619496569
Provider Name (Legal Business Name): MATTHEW SANSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2017
Last Update Date: 09/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4515 S WILLAMETTE CT
SPOKANE WA
99223-2245
US

IV. Provider business mailing address

41 E 27TH AVE
SPOKANE WA
99203-2430
US

V. Phone/Fax

Practice location:
  • Phone: 253-208-8508
  • Fax:
Mailing address:
  • Phone: 253-208-8508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: