Basic Information
| Provider Information | |||||||||
| NPI: | 1972527968 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WAARVICK | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 34581 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981241581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092417349 | ||||||||
| FaxNumber: | 5092417628 | ||||||||
| Practice Location | |||||||||
| Address1: | 504 N 40TH AVE | ||||||||
| Address2: | |||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989084311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099669480 | ||||||||
| FaxNumber: | 5099663283 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2006 | ||||||||
| LastUpdateDate: | 02/04/2022 | ||||||||
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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 | 207Q00000X | MD00044800 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8430142 | 05 | WA | MEDICAID |