Healthcare Provider Details

I. General information

NPI: 1093223299
Provider Name (Legal Business Name): JOSEPH WINTER KOTNOUR PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2018
Last Update Date: 04/26/2021
Certification Date: 04/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34515 9TH AVE S
FEDERAL WAY WA
98003-6761
US

IV. Provider business mailing address

34515 9TH AVE S
FEDERAL WAY WA
98003-6761
US

V. Phone/Fax

Practice location:
  • Phone: 253-426-6341
  • Fax: 253-426-6344
Mailing address:
  • Phone: 253-426-6341
  • Fax: 253-426-6344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60969088
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: