Provider Demographics
NPI:1972904167
Name:BRANAMAN, MATTHEW KEGAN (LMP)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:KEGAN
Last Name:BRANAMAN
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2612 NE 195TH ST
Mailing Address - Street 2:APT B10
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98155-1473
Mailing Address - Country:US
Mailing Address - Phone:770-842-4381
Mailing Address - Fax:
Practice Address - Street 1:2612 NE 195TH ST
Practice Address - Street 2:APT B10
Practice Address - City:SHORELINE
Practice Address - State:WA
Practice Address - Zip Code:98155-1473
Practice Address - Country:US
Practice Address - Phone:770-842-4381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-08
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60445384225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist