Provider Demographics
NPI:1063927663
Name:DELISI, MATTHEW S
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:S
Last Name:DELISI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:MATT
Other - Middle Name:S
Other - Last Name:DELISI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1609 9TH ST APT A
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-6843
Mailing Address - Country:US
Mailing Address - Phone:402-613-9392
Mailing Address - Fax:
Practice Address - Street 1:1609 9TH ST APT A
Practice Address - Street 2:
Practice Address - City:WENATCHEE
Practice Address - State:WA
Practice Address - Zip Code:98801-6843
Practice Address - Country:US
Practice Address - Phone:402-613-9392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-06
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE390200000X
WAA1608854362255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program