Provider Demographics
NPI:1346643608
Name:KIM, MARSHALL (NP)
Entity Type:Individual
Prefix:
First Name:MARSHALL
Middle Name:
Last Name:KIM
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14450 NE 29TH PL STE 203
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98007-8616
Mailing Address - Country:US
Mailing Address - Phone:425-998-7884
Mailing Address - Fax:
Practice Address - Street 1:14450 NE 29TH PL STE 203
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007-8616
Practice Address - Country:US
Practice Address - Phone:425-998-7884
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-01
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60637595363L00000X
CA23668363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
8951659Medicare PIN