Provider Demographics
NPI:1457085987
Name:DOHERTY, KIERAN (PA-C)
Entity type:Individual
Prefix:
First Name:KIERAN
Middle Name:
Last Name:DOHERTY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 W FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:WA
Mailing Address - Zip Code:98584-2548
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:914 S SCHEUBER RD
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-9027
Practice Address - Country:US
Practice Address - Phone:360-736-2803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-11
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA61487517363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant