Provider Demographics
NPI:1346227170
Name:MATA, JOSE
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:MATA
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 1:1728 W MARINE VIEW DR STE 110
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-2094
Mailing Address - Country:US
Mailing Address - Phone:425-259-4041
Mailing Address - Fax:425-252-6642
Practice Address - Street 1:629 AVENUE D
Practice Address - Street 2:
Practice Address - City:SNOHOMISH
Practice Address - State:WA
Practice Address - Zip Code:98290
Practice Address - Country:US
Practice Address - Phone:605-681-5543
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5866640-1205207Q00000X
WAMD00046741207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8459430Medicaid
WA8459430Medicaid