Provider Demographics
NPI:1871633131
Name:QUEYQUEP, DONNA C (MD)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:C
Last Name:QUEYQUEP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 E. KINCAID STREET
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 DRIVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273
Practice Address - Country:US
Practice Address - Phone:802-527-8189
Practice Address - Fax:802-527-8187
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV12152208000000X
WAMD60106936208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA263819OtherLABOR & INDUSTRIES
WA2005521Medicaid
WA8892569Medicare PIN