Healthcare Provider Details

I. General information

NPI: 1073283693
Provider Name (Legal Business Name): KENNETH MICHAEL WETHERHOLT CSFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2021
Last Update Date: 06/09/2026
Certification Date: 06/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2050 BARB ST
SILVERDALE WA
98315-2050
US

IV. Provider business mailing address

3093 BONEFISH CIR APT M12
SILVERDALE WA
98315-9727
US

V. Phone/Fax

Practice location:
  • Phone: 360-396-4209
  • Fax:
Mailing address:
  • Phone: 850-554-2346
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number194476
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: