Provider Demographics
NPI:1740660869
Name:WATANATRAIBHOB, MATTHEW (DPT)
Entity type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
Last Name:WATANATRAIBHOB
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3252 NE 3RD AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:CAMAS
Mailing Address - State:WA
Mailing Address - Zip Code:98607-2448
Mailing Address - Country:US
Mailing Address - Phone:360-835-7427
Mailing Address - Fax:
Practice Address - Street 1:3252 NE 3RD AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:CAMAS
Practice Address - State:WA
Practice Address - Zip Code:98607-2448
Practice Address - Country:US
Practice Address - Phone:360-835-7427
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-03
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist