=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063619922
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MATTISON PATHOLOGY, L.L.P.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2007
-----------------------------------------------------
Last Update Date | 09/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4245 N CENTRAL EXPY STE 420
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75205-4566
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-987-7284
-----------------------------------------------------
Fax | 469-232-9927
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3560 MERIDIAN ST STE 101
-----------------------------------------------------
City | BELLINGHAM
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98225-1731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-734-2800
-----------------------------------------------------
Fax | 360-734-3818
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. GREGORY M WOLGAMOT
-----------------------------------------------------
Credential | M.D., PH.D.
-----------------------------------------------------
Telephone | 866-987-7284
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZC0500X
-----------------------------------------------------
Taxonomy Name | Cytopathology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207ZP0102X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology & Clinical Pathology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------