=====================================================
General NPI Number Information
=====================================================
NPI Number | 1518822170
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KYNEISHA WATSON PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/17/2025
-----------------------------------------------------
Last Update Date | 12/17/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4311 11TH AVE NE STE 200
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98105-6367
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-616-4001
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9523 SNEAD CT
-----------------------------------------------------
City | LAUREL
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20708-3234
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-374-3743
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | C0010090
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------