Provider Demographics
NPI:1366435943
Name:MATISTA, JOHN F (PA-C)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:F
Last Name:MATISTA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1330 ROCKEFELLER AVE
Mailing Address - Street 2:SUITE 225
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-1684
Mailing Address - Country:US
Mailing Address - Phone:425-261-4910
Mailing Address - Fax:425-261-4911
Practice Address - Street 1:1330 ROCKEFELLER AVE
Practice Address - Street 2:SUITE 225
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-1684
Practice Address - Country:US
Practice Address - Phone:425-261-4910
Practice Address - Fax:425-261-4911
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004886363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8435968Medicaid
WA8435968Medicaid
WA8856052Medicare PIN