Basic Information
| Provider Information | |||||||||
| NPI: | 1740218080 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATIN | ||||||||
| FirstName: | MICHELLE | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1145 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981224201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2063291760 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11011 MERIDIAN AVE N | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981338967 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065255777 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2006 | ||||||||
| LastUpdateDate: | 03/24/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD00033221 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8199549 | 05 | WA | MEDICAID |