Healthcare Provider Details

I. General information

NPI: 1518822170
Provider Name (Legal Business Name): KYNEISHA WATSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4311 11TH AVE NE STE 200
SEATTLE WA
98105-6367
US

IV. Provider business mailing address

9523 SNEAD CT
LAUREL MD
20708-3234
US

V. Phone/Fax

Practice location:
  • Phone: 206-616-4001
  • Fax:
Mailing address:
  • Phone: 240-374-3743
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0010090
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: