Provider Demographics
NPI:1336758432
Name:THIBAULT, KALI MARIE (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:KALI
Middle Name:MARIE
Last Name:THIBAULT
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11311 BRIDGEPORT WAY SW STE 309
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499-3078
Mailing Address - Country:US
Mailing Address - Phone:253-985-2949
Mailing Address - Fax:253-985-2948
Practice Address - Street 1:11311 BRIDGEPORT WAY SW STE 309
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-3078
Practice Address - Country:US
Practice Address - Phone:253-985-2949
Practice Address - Fax:253-985-2948
Is Sole Proprietor?:No
Enumeration Date:2020-07-24
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61073932363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2165926Medicaid