Healthcare Provider Details

I. General information

NPI: 1376554154
Provider Name (Legal Business Name): KEVIN EUGENE SANDERS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 06/11/2024
Certification Date: 06/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2940 S MERIDIAN STE 100
PUYALLUP WA
98373-1659
US

IV. Provider business mailing address

2920 S MERIDIAN STE 200
PUYALLUP WA
98373-1428
US

V. Phone/Fax

Practice location:
  • Phone: 253-200-3166
  • Fax: 253-200-3167
Mailing address:
  • Phone: 532-200-3166
  • Fax: 253-200-3167

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberMD00046461
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: