Provider Demographics
NPI:1568516219
Name:JANNISON DARCEY, KIMBERLY G (PA)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:G
Last Name:JANNISON DARCEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2420 S UNION AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-1322
Mailing Address - Country:US
Mailing Address - Phone:253-272-8148
Mailing Address - Fax:253-404-0506
Practice Address - Street 1:3209 S 23RD ST
Practice Address - Street 2:SUITE 340
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-1602
Practice Address - Country:US
Practice Address - Phone:253-272-5127
Practice Address - Fax:253-272-0811
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003817363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8349045Medicaid
WAGAB37128Medicare PIN
WAGAB37131Medicare PIN
WAS79701Medicare UPIN
WA8349045Medicaid
WAGAB37127Medicare PIN
WAGAB37130Medicare PIN
WA970009385Medicare PIN
WAG8872392Medicare PIN