Provider Demographics
NPI:1518914811
Name:O'NEILL, KATHLEEN MARY (PAC)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARY
Last Name:O'NEILL
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:M
Other - Last Name:O'NEILL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PAC
Mailing Address - Street 1:1400 E KINCAID ST
Mailing Address - Street 2:ATTN: CREDENTIALING
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:360-428-2500
Mailing Address - Fax:360-428-6485
Practice Address - Street 1:2320 FREEWAY DR
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-5445
Practice Address - Country:US
Practice Address - Phone:360-814-6800
Practice Address - Fax:360-814-6917
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004305363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1057449Medicaid
WAS73202Medicare UPIN
WA8404410Medicaid
WA0225527OtherLABOR & INDUSTRY