Provider Demographics
NPI:1568974822
Name:MATSON, CODY
Entity type:Individual
Prefix:
First Name:CODY
Middle Name:
Last Name:MATSON
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 1:1312 N MONROE ST STE 271
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99201-2623
Mailing Address - Country:US
Mailing Address - Phone:208-718-2528
Mailing Address - Fax:509-232-5547
Practice Address - Street 1:2199 W IRONWOOD CENTER DR
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-2639
Practice Address - Country:US
Practice Address - Phone:208-625-4888
Practice Address - Fax:208-625-5734
Is Sole Proprietor?:No
Enumeration Date:2017-10-26
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP67131363L00000X, 2084P0800X
IAG140540363LP0808X
WAAP60967912363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry