Healthcare Provider Details

I. General information

NPI: 1558771261
Provider Name (Legal Business Name): KIRKPATRICK FAMILY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2014
Last Update Date: 05/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1706 WASHINGTON WAY
LONGVIEW WA
98632-2952
US

IV. Provider business mailing address

PO BOX 1338
LONGVIEW WA
98632-7785
US

V. Phone/Fax

Practice location:
  • Phone: 360-423-9580
  • Fax: 360-423-6230
Mailing address:
  • Phone: 360-423-9580
  • Fax: 360-423-6230

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60463399
License Number StateWA

VIII. Authorized Official

Name: STEVE TROTTER
Title or Position: DIRECTOR
Credential:
Phone: 360-423-0390