Provider Demographics
NPI:1154500536
Name:MATIACO, LISA MICHELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELLE
Last Name:MATIACO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:10 ROS CIR
Mailing Address - Street 2:
Mailing Address - City:REPUBLIC
Mailing Address - State:WA
Mailing Address - Zip Code:99166-5002
Mailing Address - Country:US
Mailing Address - Phone:509-775-3153
Mailing Address - Fax:509-775-8929
Practice Address - Street 1:10 ROS CIR
Practice Address - Street 2:
Practice Address - City:REPUBLIC
Practice Address - State:WA
Practice Address - Zip Code:99166-5002
Practice Address - Country:US
Practice Address - Phone:509-775-3153
Practice Address - Fax:509-775-8929
Is Sole Proprietor?:No
Enumeration Date:2007-11-01
Last Update Date:2013-03-21
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant