Provider Demographics
NPI:1114306644
Name:HERRON, KACY J (MD)
Entity Type:Individual
Prefix:
First Name:KACY
Middle Name:J
Last Name:HERRON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1401 MADISON ST STE 100
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104
Practice Address - Country:US
Practice Address - Phone:206-386-6111
Practice Address - Fax:206-386-6113
Is Sole Proprietor?:No
Enumeration Date:2015-05-29
Last Update Date:2018-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMRM-1480207Q00000X
WAMD60828698207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine