Basic Information
| Provider Information | |||||||||
| NPI: | 1457603532 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MATSUMOTO | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | PA-C, MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1959 NE PACIFIC STREET BOX 356421 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981956241 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065433605 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1959 NE PACIFIC STREET BOX : 356421 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981950001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2065433605 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2012 | ||||||||
| LastUpdateDate: | 06/08/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 60310464 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207R00000X | ML61058307 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.