Provider Demographics
NPI:1275936684
Name:PHILLIPS, KATHRYN MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:MARIE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KATHRYN
Other - Middle Name:MARIE
Other - Last Name:PIERCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3209 S 23RD ST
Mailing Address - Street 2:STE 340
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-1602
Mailing Address - Country:US
Mailing Address - Phone:253-383-8342
Mailing Address - Fax:253-572-8204
Practice Address - Street 1:33915 1ST WAY S
Practice Address - Street 2:STE 200
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-4551
Practice Address - Country:US
Practice Address - Phone:253-838-9839
Practice Address - Fax:253-661-9077
Is Sole Proprietor?:No
Enumeration Date:2014-09-29
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA.60490709363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG001045700OtherGROUP PTAN(P)
WA2044171Medicaid
WAG000188100OtherGROUP PTAN(K)
WAG000188100OtherGROUP PTAN(K)
WA2044171Medicaid