Basic Information
| Provider Information | |||||||||
| NPI: | 1063776441 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ATKINSON | ||||||||
| FirstName: | MATTHEW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3939 NW CLARENCE CIR | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973306548 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5419083173 | ||||||||
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| Practice Location | |||||||||
| Address1: | 530 NW 27TH ST | ||||||||
| Address2: | |||||||||
| City: | CORVALLIS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973305223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417666835 | ||||||||
| FaxNumber: | 5417666186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2012 | ||||||||
| LastUpdateDate: | 06/29/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | PI-0011158 | OR | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.