Healthcare Provider Details

I. General information

NPI: 1588907505
Provider Name (Legal Business Name): KEVIN SHI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2013
Last Update Date: 03/10/2020
Certification Date: 03/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

970 DENNY WAY
SEATTLE WA
98109-5201
US

IV. Provider business mailing address

1 EMBARCADERO CTR STE 1900
SAN FRANCISCO CA
94111-3723
US

V. Phone/Fax

Practice location:
  • Phone: 206-267-4390
  • Fax: 206-267-4391
Mailing address:
  • Phone: 415-658-6791
  • Fax: 415-520-0904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61024630
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2016-0014
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: