Provider Demographics
NPI:1609908482
Name:PATTILLO, MATTHEW (PT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:PATTILLO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7201 W CLEARWATER AVE
Mailing Address - Street 2:SUITE B101
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-1694
Mailing Address - Country:US
Mailing Address - Phone:509-544-0265
Mailing Address - Fax:509-987-1614
Practice Address - Street 1:907 S AUBURN ST
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-5662
Practice Address - Country:US
Practice Address - Phone:509-582-0429
Practice Address - Fax:509-582-1182
Is Sole Proprietor?:No
Enumeration Date:2007-03-09
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00008176225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0186430OtherLABOR & INDUSTRIES
WA8336455Medicaid
WA0186430OtherLABOR & INDUSTRIES