Provider Demographics
NPI:1982628129
Name:HERRON, KEVIN (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:HERRON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 153RD ST SE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MILL CREEK
Mailing Address - State:WA
Mailing Address - Zip Code:98012-4051
Mailing Address - Country:US
Mailing Address - Phone:425-745-4750
Mailing Address - Fax:425-745-6158
Practice Address - Street 1:1025 153RD ST SE
Practice Address - Street 2:SUITE 200
Practice Address - City:MILL CREEK
Practice Address - State:WA
Practice Address - Zip Code:98012-4051
Practice Address - Country:US
Practice Address - Phone:425-745-4750
Practice Address - Fax:425-745-6158
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00040146207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAH69639Medicare UPIN
WA8855172Medicare ID - Type Unspecified