Basic Information
| Provider Information | |||||||||
| NPI: | 1508258310 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAHAFFEY | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5111 76TH AVENUE CT W | ||||||||
| Address2: | |||||||||
| City: | UNIVERSITY PLACE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984674597 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602244665 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11411 BRIDGEPORT WAY SW | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984993047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535819002 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2015 | ||||||||
| LastUpdateDate: | 05/10/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA60696945 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 2069443 | 05 | WA | MEDICAID |