Provider Demographics
NPI:1073010526
Name:PETTERSEN, MATTHEW (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:PETTERSEN
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1704 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98225-4605
Mailing Address - Country:US
Mailing Address - Phone:360-922-3120
Mailing Address - Fax:
Practice Address - Street 1:810 NW 195TH ST
Practice Address - Street 2:
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98177-2662
Practice Address - Country:US
Practice Address - Phone:205-251-3747
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-11
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer