Provider Demographics
NPI:1093002172
Name:DEPAZ, KANYAKANIT BUPPAWONG (LMP)
Entity Type:Individual
Prefix:MRS
First Name:KANYAKANIT
Middle Name:BUPPAWONG
Last Name:DEPAZ
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 146TH PL NE
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98007-4941
Mailing Address - Country:US
Mailing Address - Phone:206-235-5557
Mailing Address - Fax:
Practice Address - Street 1:14850 LAKE HILLS BLVD
Practice Address - Street 2:# 4
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007-5800
Practice Address - Country:US
Practice Address - Phone:425-558-9441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-08
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 00024931172M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172M00000XOther Service ProvidersMechanotherapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMA 00024931OtherLMP