Provider Demographics
NPI:1538467329
Name:WADDINGHAM, MATTHEW GARY (CO)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:GARY
Last Name:WADDINGHAM
Suffix:
Gender:M
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 S CEDAR ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-2308
Mailing Address - Country:US
Mailing Address - Phone:253-572-1282
Mailing Address - Fax:253-572-1175
Practice Address - Street 1:34709 9TH AVE S
Practice Address - Street 2:SUITE A-100
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-8722
Practice Address - Country:US
Practice Address - Phone:253-952-3887
Practice Address - Fax:253-927-3058
Is Sole Proprietor?:No
Enumeration Date:2011-03-03
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOI60206377174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist