Provider Demographics
NPI:1245748383
Name:WYSOCKI, MATTHEW FREDERICK
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:FREDERICK
Last Name:WYSOCKI
Suffix:
Gender:M
Credentials:
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 629
Mailing Address - Street 2:
Mailing Address - City:GRANITE FALLS
Mailing Address - State:WA
Mailing Address - Zip Code:98252-0629
Mailing Address - Country:US
Mailing Address - Phone:520-260-3458
Mailing Address - Fax:
Practice Address - Street 1:5118 BOSWORTH DR
Practice Address - Street 2:
Practice Address - City:SNOHOMISH
Practice Address - State:WA
Practice Address - Zip Code:98290-7700
Practice Address - Country:US
Practice Address - Phone:520-260-3458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-10
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist