Provider Demographics
NPI:1467548685
Name:HERZOG, KIM JENNIFER (PAC)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:JENNIFER
Last Name:HERZOG
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:GERSHOWITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:909 N BROADWAY
Mailing Address - Street 2:PBO
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-1409
Mailing Address - Country:US
Mailing Address - Phone:425-317-0699
Mailing Address - Fax:425-317-0291
Practice Address - Street 1:1001 N BROADWAY
Practice Address - Street 2:SUITE A-3
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-1586
Practice Address - Country:US
Practice Address - Phone:425-317-0300
Practice Address - Fax:425-317-0303
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004579363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8384745Medicaid
WA8384745Medicaid
WAG8878734Medicare PIN
WA8802441Medicare ID - Type Unspecified