Healthcare Provider Details

I. General information

NPI: 1851497549
Provider Name (Legal Business Name): KYLE THOMAS KREKOW PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 06/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14720 MAIN ST NE SUITE 109
DUVALL WA
98019-8460
US

IV. Provider business mailing address

PO BOX 34036
SEATTLE WA
98124-1036
US

V. Phone/Fax

Practice location:
  • Phone: 425-788-4889
  • Fax: 425-844-6116
Mailing address:
  • Phone: 425-899-3292
  • Fax: 425-899-3269

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10005050
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: