Provider Demographics
NPI:1972288298
Name:DE LA MATER, MICHAEL ARTHUR (PSS)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:ARTHUR
Last Name:DE LA MATER
Suffix:
Gender:M
Credentials:PSS
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 1710
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-0516
Mailing Address - Country:US
Mailing Address - Phone:541-504-9577
Mailing Address - Fax:
Practice Address - Street 1:850 SE 4TH ST
Practice Address - Street 2:
Practice Address - City:MADRAS
Practice Address - State:OR
Practice Address - Zip Code:97741-9629
Practice Address - Country:US
Practice Address - Phone:541-475-6575
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000104906175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist