Provider Demographics
NPI:1285818815
Name:KUMMERFELDT, MATHEW (PA-C)
Entity Type:Individual
Prefix:
First Name:MATHEW
Middle Name:
Last Name:KUMMERFELDT
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1668
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-5001
Mailing Address - Country:US
Mailing Address - Phone:360-426-2653
Mailing Address - Fax:888-985-0681
Practice Address - Street 1:1701 N 13TH ST
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:WA
Practice Address - Zip Code:98584-2077
Practice Address - Country:US
Practice Address - Phone:360-426-2653
Practice Address - Fax:888-985-0681
Is Sole Proprietor?:No
Enumeration Date:2007-12-18
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0273939OtherL&I
WA0275126OtherL&I
WA8946032OtherSTATE CRIME VICTIMS
WA8502049Medicaid
WA0228031OtherSTATE L&I
WA0275142OtherL&I
WAP00610661OtherRAILROAD
WAG8870074Medicare PIN
WA0228031OtherSTATE L&I
WAG8898553Medicare PIN
WA0275126OtherL&I