Provider Demographics
NPI:1982684833
Name:PRUESS NEVINS, KIM ELIZABETH (MD)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:ELIZABETH
Last Name:PRUESS NEVINS
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:PO BOX 1225
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-0047
Mailing Address - Country:US
Mailing Address - Phone:425-391-0313
Mailing Address - Fax:425-837-8501
Practice Address - Street 1:450 NW GILMAN BLVD
Practice Address - Street 2:SUITE 301A
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-2483
Practice Address - Country:US
Practice Address - Phone:425-391-0313
Practice Address - Fax:425-837-8501
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00038616207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0160710OtherDEPT OF L & I
110235772OtherRAILROAD MEDICARE
WA1116037Medicaid
WA6232PROtherREGENCE BLUE SHIELD
H06295Medicare UPIN
WA6232PROtherREGENCE BLUE SHIELD