Provider Demographics
NPI:1033128459
Name:MCDANIEL, KATHLEEN A (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:A
Last Name:MCDANIEL
Suffix:
Gender:F
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 1:11511 CANTERWOOD BLVD STE 205
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98332-5818
Mailing Address - Country:US
Mailing Address - Phone:253-530-2663
Mailing Address - Fax:
Practice Address - Street 1:11511 CANTERWOOD BLVD STE 205
Practice Address - Street 2:
Practice Address - City:GIG HARBOR
Practice Address - State:WA
Practice Address - Zip Code:98332-5818
Practice Address - Country:US
Practice Address - Phone:253-530-2663
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2020-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003808363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0201042OtherSTATE L&I
WA0201048OtherSTATE L&I
WA1042578Medicaid
WAG8893636Medicare PIN
WAG8367286Medicare PIN
WA0201042OtherSTATE L&I
8850002Medicare ID - Type Unspecified
WAG8855145Medicare PIN