Provider Demographics
NPI:1124011408
Name:MORIMOTO, KAIULANI WILSON (MD FACS)
Entity Type:Individual
Prefix:
First Name:KAIULANI
Middle Name:WILSON
Last Name:MORIMOTO
Suffix:
Gender:F
Credentials:MD FACS
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:KAIULANI
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12615 E MISSION AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99216-1047
Mailing Address - Country:US
Mailing Address - Phone:509-315-4415
Mailing Address - Fax:509-315-8204
Practice Address - Street 1:12615 E MISSION AVE STE 105
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99216-1047
Practice Address - Country:US
Practice Address - Phone:509-315-4415
Practice Address - Fax:509-315-8204
Is Sole Proprietor?:No
Enumeration Date:2005-08-23
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00036728208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8394512Medicaid
WA8394512Medicaid
WA8803247Medicare ID - Type Unspecified