Provider Demographics
NPI:1558104737
Name:CORCORAN-SIPE, KEGAN YU (LMT)
Entity type:Individual
Prefix:
First Name:KEGAN
Middle Name:YU
Last Name:CORCORAN-SIPE
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:KEGAN
Other - Middle Name:YU
Other - Last Name:SIPE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4030 ALDERWOOD MALL BLVD
Mailing Address - Street 2:
Mailing Address - City:LYNNWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98036-6763
Mailing Address - Country:US
Mailing Address - Phone:425-776-0803
Mailing Address - Fax:
Practice Address - Street 1:4030 ALDERWOOD MALL BLVD
Practice Address - Street 2:
Practice Address - City:LYNNWOOD
Practice Address - State:WA
Practice Address - Zip Code:98036-6763
Practice Address - Country:US
Practice Address - Phone:425-776-0803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-17
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA61320012225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist