Healthcare Provider Details

I. General information

NPI: 1558773937
Provider Name (Legal Business Name): KEVIN PENN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2014
Last Update Date: 11/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 SENECA ST
SEATTLE WA
98101-2742
US

IV. Provider business mailing address

1811 26TH AVE S UNIT B
SEATTLE WA
98144-4715
US

V. Phone/Fax

Practice location:
  • Phone: 206-583-6079
  • Fax:
Mailing address:
  • Phone: 970-978-8595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number60469953
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number60903199
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: