Provider Demographics
NPI:1851497549
Name:KREKOW, KYLE THOMAS (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KYLE
Middle Name:THOMAS
Last Name:KREKOW
Suffix:
Gender:M
Credentials:PA-C
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 34036
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1036
Mailing Address - Country:US
Mailing Address - Phone:425-899-3292
Mailing Address - Fax:425-899-3269
Practice Address - Street 1:14720 MAIN ST NE
Practice Address - Street 2:SUITE 109
Practice Address - City:DUVALL
Practice Address - State:WA
Practice Address - Zip Code:98019-8460
Practice Address - Country:US
Practice Address - Phone:425-788-4889
Practice Address - Fax:425-844-6116
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10005050363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00447839OtherMEDICARE RAILROAD
WA8463747Medicaid
WAG8862371Medicare PIN
WA8463747Medicaid