Basic Information
| Provider Information | |||||||||
| NPI: | 1578509444 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KELLOGG | ||||||||
| FirstName: | WILL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 97115 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984970115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535887911 | ||||||||
| FaxNumber: | 2533656299 | ||||||||
| Practice Location | |||||||||
| Address1: | 1901 S UNION AVE | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984051702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603377880 | ||||||||
| FaxNumber: | 3603377881 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 11/19/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | MD00034368 | WA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 0127354 | 01 | WA | LABOR& INDUSTRIES | OTHER | 1107614 | 05 | WA | MEDICAID | 8935812 | 01 | WA | CRIME VICTIMS | OTHER | KE5497 | 01 | WA | REGENCE BLUESHIELD | OTHER |