Provider Demographics
NPI:1255311122
Name:KIM PRUESS NEVINS MD PLLC
Entity Type:Organization
Organization Name:KIM PRUESS NEVINS MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:PRUESS NEVINS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-391-0313
Mailing Address - Street 1:PO BOX 1225
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-0047
Mailing Address - Country:US
Mailing Address - Phone:425-391-0313
Mailing Address - Fax:425-837-8501
Practice Address - Street 1:450 NW GILMAN BLVD
Practice Address - Street 2:STE 301A
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027
Practice Address - Country:US
Practice Address - Phone:425-391-0313
Practice Address - Fax:425-837-8501
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-18
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00038616207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DC8003OtherRAILROAD MEDICARE
DC8003OtherRAILROAD MEDICARE