Provider Demographics
NPI:1710461652
Name:ROTHSTROM, MATTHEW JONATHON (PA-C)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JONATHON
Last Name:ROTHSTROM
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19 CASCADE DR
Mailing Address - Street 2:
Mailing Address - City:WALLA WALLA
Mailing Address - State:WA
Mailing Address - Zip Code:99362-2509
Mailing Address - Country:US
Mailing Address - Phone:509-540-8237
Mailing Address - Fax:
Practice Address - Street 1:7320 216TH ST SW STE 320
Practice Address - Street 2:
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-8006
Practice Address - Country:US
Practice Address - Phone:425-673-3900
Practice Address - Fax:425-673-3910
Is Sole Proprietor?:No
Enumeration Date:2018-09-17
Last Update Date:2018-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60872146363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2110750Medicaid