Healthcare Provider Details

I. General information

NPI: 1164527206
Provider Name (Legal Business Name): KURT SANDINE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3928 PACIFIC AVE SE
LACEY WA
98503-1109
US

IV. Provider business mailing address

823 MCCORMICK ST SE
OLYMPIA WA
98501-1738
US

V. Phone/Fax

Practice location:
  • Phone: 360-455-1350
  • Fax: 360-455-5354
Mailing address:
  • Phone: 360-866-6868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00044314
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: