Provider Demographics
NPI:1255823654
Name:WADSWORTH, KIM (DO)
Entity type:Individual
Prefix:DR
First Name:KIM
Middle Name:
Last Name:WADSWORTH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:KIM
Other - Middle Name:
Other - Last Name:HA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 13082
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98508-3082
Mailing Address - Country:US
Mailing Address - Phone:360-688-1151
Mailing Address - Fax:360-282-0738
Practice Address - Street 1:405 BLACK HILLS LN SW STE B2
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-8661
Practice Address - Country:US
Practice Address - Phone:360-688-1151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-31
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOL60864834207Q00000X
WAOP61075127207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2102267Medicaid