Provider Demographics
NPI:1366837510
Name:MATELICH, LISA CLAIRE (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:CLAIRE
Last Name:MATELICH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LISA
Other - Middle Name:CLAIRE
Other - Last Name:GROVE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:714 W PINE ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:WA
Mailing Address - Zip Code:99156-9046
Mailing Address - Country:US
Mailing Address - Phone:509-447-3139
Mailing Address - Fax:
Practice Address - Street 1:714 W PINE ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:WA
Practice Address - Zip Code:99156-9046
Practice Address - Country:US
Practice Address - Phone:509-474-3139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-04
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60890428207Q00000X
COTL.0005926207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program