Provider Demographics
NPI:1376239012
Name:MATHIS, NATASHA
Entity Type:Individual
Prefix:
First Name:NATASHA
Middle Name:
Last Name:MATHIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NATASHA
Other - Middle Name:
Other - Last Name:BACA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:621 S LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-6111
Mailing Address - Country:US
Mailing Address - Phone:360-452-9784
Mailing Address - Fax:
Practice Address - Street 1:621 S LINCOLN ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-6111
Practice Address - Country:US
Practice Address - Phone:360-452-9784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-14
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAVA61357449183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician