1013512631 NPI number — KATHLEEN MARGARET MISHUROV PHARMD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013512631 NPI number — KATHLEEN MARGARET MISHUROV PHARMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MISHUROV
Provider First Name:
KATHLEEN
Provider Middle Name:
MARGARET
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHARMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HEALY
Provider Other First Name:
KATHLEEN
Provider Other Middle Name:
MARGARET
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHARMD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1013512631
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/01/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24106 185TH LOOP SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COVINGTON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98042-4897
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-478-1248
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15615 BEL RED RD STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BELLEVUE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98008-2300
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
425-881-0222
Provider Business Practice Location Address Fax Number:
425-885-1213
Provider Enumeration Date:
12/01/2020

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: 183500000X , with the licence number:  PH60753576 , 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)





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