Provider Demographics
NPI:1902850803
Name:DAWSON, KIRK (DO)
Entity Type:Individual
Prefix:
First Name:KIRK
Middle Name:
Last Name:DAWSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4570 AVERY LN SE
Mailing Address - Street 2:STE C-180
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503
Mailing Address - Country:US
Mailing Address - Phone:360-528-7122
Mailing Address - Fax:
Practice Address - Street 1:202 CULLENS ST NW
Practice Address - Street 2:
Practice Address - City:YELM
Practice Address - State:WA
Practice Address - Zip Code:98597-9417
Practice Address - Country:US
Practice Address - Phone:360-458-7761
Practice Address - Fax:360-458-6612
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-22
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001279207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA72333OtherL&I
WA1073360Medicaid
WADA7849OtherREGENCE
AB07110Medicare ID - Type Unspecified
WA72333OtherL&I