Basic Information
| Provider Information | |||||||||
| NPI: | 1124420674 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OSBORNE | ||||||||
| FirstName: | KATHRYN | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | OSBORNE | ||||||||
| OtherFirstName: | KATE | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1780 NW MYHRE RD STE 1220 | ||||||||
| Address2: | |||||||||
| City: | SILVERDALE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983838676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606984505 | ||||||||
| FaxNumber: | 2539526824 | ||||||||
| Practice Location | |||||||||
| Address1: | 1780 NW MYHRE RD STE 1220 | ||||||||
| Address2: | |||||||||
| City: | SILVERDALE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983838676 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3606984505 | ||||||||
| FaxNumber: | 2539526824 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2014 | ||||||||
| LastUpdateDate: | 12/08/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA60611261 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | PA60611261 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AM0700X | PA60611261 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 2050138 | 05 | WA | MEDICAID |