Basic Information
| Provider Information | |||||||||
| NPI: | 1568032076 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | COSTA | ||||||||
| FirstName: | MATIAS | ||||||||
| MiddleName: | LUIS | ||||||||
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| NameSuffix: | SR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1215 DEXTER AVE N APT 202 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981093545 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2068253810 | ||||||||
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| Practice Location | |||||||||
| Address1: | 550 17TH AVE | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981225788 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063202800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2021 | ||||||||
| LastUpdateDate: | 06/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | MDFE.FE.61186248 | WA | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
No ID Information.