Healthcare Provider Details

I. General information

NPI: 1457085987
Provider Name (Legal Business Name): KIERAN DOHERTY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2022
Last Update Date: 12/18/2025
Certification Date: 12/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2003 KOOTENAI HEALTH WAY
COEUR D ALENE ID
83814-6051
US

IV. Provider business mailing address

706 W FRANKLIN ST
SHELTON WA
98584-2548
US

V. Phone/Fax

Practice location:
  • Phone: 208-625-5200
  • Fax: 208-625-5201
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5971256
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61487517
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: