Provider Demographics
NPI:1881218089
Name:HUNTSMAN, MICHAEL KEEGAN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:KEEGAN
Last Name:HUNTSMAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1400 E KINCAID ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4127
Mailing Address - Country:US
Mailing Address - Phone:360-814-6451
Mailing Address - Fax:360-445-8592
Practice Address - Street 1:875 WESLEY ST STE 230
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:WA
Practice Address - Zip Code:98223-1668
Practice Address - Country:US
Practice Address - Phone:360-435-6097
Practice Address - Fax:360-435-1871
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-03
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOA61091541363AS0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program