Provider Demographics
NPI:1134162308
Name:K-Y SURGICAL ASSOC
Entity type:Organization
Organization Name:K-Y SURGICAL ASSOC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LOU
Authorized Official - Middle Name:
Authorized Official - Last Name:JOUBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:253-274-9732
Mailing Address - Street 1:5121 CROMWELL DR NW
Mailing Address - Street 2:
Mailing Address - City:GIG HARBOR
Mailing Address - State:WA
Mailing Address - Zip Code:98335-7545
Mailing Address - Country:US
Mailing Address - Phone:253-274-9732
Mailing Address - Fax:253-274-9736
Practice Address - Street 1:1307 S 11TH ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-3644
Practice Address - Country:US
Practice Address - Phone:253-274-9732
Practice Address - Fax:253-274-9736
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7132731Medicaid
WA7132731Medicaid