Provider Demographics
NPI:1407951395
Name:HARTHCOCK, KERRY A (MD)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:A
Last Name:HARTHCOCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1806 W LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-2473
Mailing Address - Country:US
Mailing Address - Phone:509-452-4520
Mailing Address - Fax:509-452-5224
Practice Address - Street 1:1806 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-2473
Practice Address - Country:US
Practice Address - Phone:509-452-4520
Practice Address - Fax:509-452-5224
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2011-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00025367208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA009865OtherLABOR AND INDUSTRIES
WA1045640Medicaid
WA8941847OtherL&I CRIME VICTIM NUMBER
WAAB38059Medicare Oscar/Certification
WA009865OtherLABOR AND INDUSTRIES
WA8941847OtherL&I CRIME VICTIM NUMBER