Healthcare Provider Details

I. General information

NPI: 1487157020
Provider Name (Legal Business Name): PRIM PREY KY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: PRIM PREY LY

II. Dates (important events)

Enumeration Date: 03/09/2018
Last Update Date: 08/27/2026
Certification Date: 08/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 GELLERT BLVD
DALY CITY CA
94015-2613
US

IV. Provider business mailing address

PO BOX 2928
PORTLAND OR
97208-2928
US

V. Phone/Fax

Practice location:
  • Phone: 650-270-2394
  • Fax:
Mailing address:
  • Phone: 425-207-5155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60763223
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61240
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: