Healthcare Provider Details

I. General information

NPI: 1023392529
Provider Name (Legal Business Name): KRISTIE MICHELLE MATTERN PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2011
Last Update Date: 06/20/2022
Certification Date: 06/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7902 27TH ST W STE 7A
UNIVERSITY PLACE WA
98466-3431
US

IV. Provider business mailing address

7902 27TH ST W STE 7A
UNIVERSITY PLACE WA
98466-3431
US

V. Phone/Fax

Practice location:
  • Phone: 253-500-4059
  • Fax: 253-503-7977
Mailing address:
  • Phone: 253-346-8859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10003450
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA10003450
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: