Basic Information
| Provider Information | |||||||||
| NPI: | 1922151612 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GMEINER | ||||||||
| FirstName: | KJERSTEN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10030 SW 210TH ST | ||||||||
| Address2: | |||||||||
| City: | VASHON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980706584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064633671 | ||||||||
| FaxNumber: | 2064633613 | ||||||||
| Practice Location | |||||||||
| Address1: | 10030 SW 210TH ST | ||||||||
| Address2: | |||||||||
| City: | VASHON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980706584 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064633671 | ||||||||
| FaxNumber: | 2064633613 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2007 | ||||||||
| LastUpdateDate: | 12/19/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | C53440 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD00039154 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 332441 | 01 | WA | STATE L&I | OTHER | 8275638 | 05 | WA | MEDICAID |