Provider Demographics
NPI:1720121361
Name:KIMBROUGH, TYLER GRAHAM (MD)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:GRAHAM
Last Name:KIMBROUGH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 MADISON ST
Mailing Address - Street 2:SUITE 901
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-1172
Mailing Address - Country:US
Mailing Address - Phone:206-264-8100
Mailing Address - Fax:206-264-8689
Practice Address - Street 1:21616 76TH AVE W
Practice Address - Street 2:SUITE 112
Practice Address - City:EDMONDS
Practice Address - State:WA
Practice Address - Zip Code:98026-7512
Practice Address - Country:US
Practice Address - Phone:425-775-6651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60667019207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8882307OtherMEDICARE NON-KING CO.
WAG8882308OtherMEDICARE KING CO