1447258496 NPI number — KIMBERLY A MEBUST MD

Table of content: KIMBERLY A MEBUST MD (NPI 1447258496)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447258496 NPI number — KIMBERLY A MEBUST MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MEBUST
Provider First Name:
KIMBERLY
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1447258496
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
915 6TH AVE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
TACOMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98405-4682
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-403-7299
Provider Business Mailing Address Fax Number:
253-403-7298

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
915 6TH AVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
TACOMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98405-4682
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-403-7299
Provider Business Practice Location Address Fax Number:
253-403-7298
Provider Enumeration Date:
07/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  25778 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 173F00000X , with the licence number: MD00033517 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 8193377 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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