Provider Demographics
NPI:1326443227
Name:DIDONATO, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:DIDONATO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8750 TALLON LN NE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98516-6608
Mailing Address - Country:US
Mailing Address - Phone:360-456-1072
Mailing Address - Fax:360-459-9954
Practice Address - Street 1:8750 TALLON LN NE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-6608
Practice Address - Country:US
Practice Address - Phone:360-456-1072
Practice Address - Fax:360-459-9954
Is Sole Proprietor?:No
Enumeration Date:2014-11-04
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60467500225100000X, 2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAPT60467500OtherSTATE LICENSE