Basic Information
| Provider Information | |||||||||
| NPI: | 1548502586 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATOSICH | ||||||||
| FirstName: | STEPHENIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 421 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990190421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8667472455 | ||||||||
| FaxNumber: | 5092277070 | ||||||||
| Practice Location | |||||||||
| Address1: | 624 E FRONT AVE | ||||||||
| Address2: | |||||||||
| City: | SPOKANE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 992022139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5096269900 | ||||||||
| FaxNumber: | 5092277070 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2013 | ||||||||
| LastUpdateDate: | 06/17/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 39229 | SC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 25337 | MS | N | Allopathic & Osteopathic Physicians | Family Medicine | 207VX0000X | 25337 | MS | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Obstetrics | 207Q00000X | TO60905528 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 392293 | 05 | SC | MEDICAID | P01772182 | 01 | SC | RAILROAD MEDICARE | OTHER |