Basic Information
Provider Information | |||||||||
NPI: | 1063529329 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MURRAY | ||||||||
FirstName: | KERRY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | LMT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2512 WHEATON WAY | ||||||||
Address2: |   | ||||||||
City: | BREMERTON | ||||||||
State: | WA | ||||||||
PostalCode: | 983103399 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 19245 7TH AVE NE | ||||||||
Address2: |   | ||||||||
City: | POULSBO | ||||||||
State: | WA | ||||||||
PostalCode: | 983706551 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3607823500 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/24/2006 | ||||||||
LastUpdateDate: | 10/30/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225700000X | MA00019054 | WA | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Massage Therapist |   |
ID Information
ID | Type | State | Issuer | Description | 219463 | 01 | WA | LABOR & INDUSTRIES | OTHER | 8918MU | 01 |   | REGENCE BLUESHIELD | OTHER | 7722889 | 01 |   | AETNA | OTHER |