Healthcare Provider Details

I. General information

NPI: 1922428952
Provider Name (Legal Business Name): MR. KEVIN KIM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2014
Last Update Date: 03/23/2023
Certification Date: 03/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33501 1ST WAY S
FEDERAL WAY WA
98003-6208
US

IV. Provider business mailing address

33501 1ST WAY S
FEDERAL WAY WA
98003-6208
US

V. Phone/Fax

Practice location:
  • Phone: 253-838-2400
  • Fax: 253-874-1637
Mailing address:
  • Phone: 253-838-2400
  • Fax: 253-874-1637

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA138163
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD60941703
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: