MEDICARE: C. KEVIN BULLEY M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	MD00023183	WA

General Provider Information

NPI Number	:	1083611768
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	C. KEVIN BULLEY M.D.

Provider Business Mailing Address
First Line	:	PO BOX 5127
Second Line	:
City	:	EVERETT
State	:	WA
Zip	:	98206-5127
Country	:	US
Telephone Number	:	253-537-0293
Fax Number	:	253-537-7650

Provider Business Practice Location Address
First Line	:	11019 CANYON RD E
Second Line	:	STE. A
City	:	PUYALLUP
State	:	WA
Zip	:	98373-3001
Country	:	US
Telephone Number	:	253-537-0293
Fax Number	:	253-537-7650

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/07/2005
Last Update Date	:	09/11/2020

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