Provider Demographics
NPI:1295226355
Name:THAI, KRISTIN JUNE BRADEN (DO)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:JUNE BRADEN
Last Name:THAI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:JUNE
Other - Last Name:BRADEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
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:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:4100 SW ALASKA ST STE B
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98116-4527
Practice Address - Country:US
Practice Address - Phone:206-320-4476
Practice Address - Fax:206-568-7043
Is Sole Proprietor?:No
Enumeration Date:2018-05-24
Last Update Date:2024-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP61064862207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2104470Medicaid