Provider Demographics
NPI:1659419398
Name:MATHISON, MARTY EUGENE (LMP)
Entity Type:Individual
Prefix:MR
First Name:MARTY
Middle Name:EUGENE
Last Name:MATHISON
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 NW CRESCENT RD
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:WA
Mailing Address - Zip Code:98944-9669
Mailing Address - Country:US
Mailing Address - Phone:509-830-6515
Mailing Address - Fax:509-837-3876
Practice Address - Street 1:711 E LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:WA
Practice Address - Zip Code:98944-2318
Practice Address - Country:US
Practice Address - Phone:509-839-4222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00006441246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other