Provider Demographics
NPI:1851386973
Name:HILLIARD, KENNETH L (DPM)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:L
Last Name:HILLIARD
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 E MAIN
Mailing Address - Street 2:SUITE 101
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-6768
Mailing Address - Country:US
Mailing Address - Phone:253-445-1682
Mailing Address - Fax:253-770-3833
Practice Address - Street 1:1011 E MAIN
Practice Address - Street 2:SUITE 101
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-6779
Practice Address - Country:US
Practice Address - Phone:253-445-1682
Practice Address - Fax:253-770-3833
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2008-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO00000267213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
756480629OtherRAILROAD MEDICARE
WA1508506Medicaid
HI0901OtherREGENCE BLUESHIELD
G001000498Medicare PIN
WA1508506Medicaid
0957930001Medicare NSC