Healthcare Provider Details

I. General information

NPI: 1467548685
Provider Name (Legal Business Name): KIM JENNIFER HERZOG PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KIM GERSHOWITZ PAC

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 02/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 N BROADWAY SUITE A-3
EVERETT WA
98201-1586
US

IV. Provider business mailing address

909 N BROADWAY PBO
EVERETT WA
98201-1409
US

V. Phone/Fax

Practice location:
  • Phone: 425-317-0300
  • Fax: 425-317-0303
Mailing address:
  • Phone: 425-317-0699
  • Fax: 425-317-0291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10004579
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: