Healthcare Provider Details

I. General information

NPI: 1336508423
Provider Name (Legal Business Name): MATTHEW BOGOYAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2016
Last Update Date: 11/04/2020
Certification Date: 11/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 S 4TH AVE
YAKIMA WA
98902-3546
US

IV. Provider business mailing address

PO BOX 959
YAKIMA WA
98907-0959
US

V. Phone/Fax

Practice location:
  • Phone: 509-575-4084
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberOP61071356
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberOS15769
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: