Provider Demographics
NPI:1669439451
Name:MATYAC, CARRIE ANN (ARNP)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:ANN
Last Name:MATYAC
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2555 MARVIN RD NE
Practice Address - Street 2:PMG SW WA HAWKS PRAIRIE IM
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-3138
Practice Address - Country:US
Practice Address - Phone:360-923-4600
Practice Address - Fax:360-412-2256
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30006999363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO18123040Medicaid