Provider Demographics
NPI:1497897227
Name:CONWAY, KEVIN DONALD (LMP)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:DONALD
Last Name:CONWAY
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 286
Mailing Address - Street 2:
Mailing Address - City:MONTESANO
Mailing Address - State:WA
Mailing Address - Zip Code:98563-0286
Mailing Address - Country:US
Mailing Address - Phone:360-581-2030
Mailing Address - Fax:360-537-8756
Practice Address - Street 1:2700 SIMPSON AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-4335
Practice Address - Country:US
Practice Address - Phone:360-581-2030
Practice Address - Fax:360-537-8756
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00017460174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0165584OtherSTATE OF WA ID NUMBER
WACO6182OtherREGENCE PROVIDER NUMBER