Provider Demographics
NPI:1235244096
Name:MAYHEW, KERRY L (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KERRY
Middle Name:L
Last Name:MAYHEW
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 1:25 HAUSSLER RD
Mailing Address - Street 2:
Mailing Address - City:OMAK
Mailing Address - State:WA
Mailing Address - Zip Code:98841-9591
Mailing Address - Country:US
Mailing Address - Phone:509-826-6832
Mailing Address - Fax:
Practice Address - Street 1:1007 KOALA AVE
Practice Address - Street 2:
Practice Address - City:OMAK
Practice Address - State:WA
Practice Address - Zip Code:98841-9247
Practice Address - Country:US
Practice Address - Phone:509-826-8443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10001928363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA127522OtherL&I
WA1003797Medicaid
WAR31459Medicare UPIN
WA127522OtherL&I