Provider Demographics
NPI:1972589422
Name:EWING, KRISTINE KELLEY (MD)
Entity type:Individual
Prefix:DR
First Name:KRISTINE
Middle Name:KELLEY
Last Name:EWING
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6968 NE ENETAI LANE
Mailing Address - Street 2:
Mailing Address - City:SUQUAMISH
Mailing Address - State:WA
Mailing Address - Zip Code:98392-5147
Mailing Address - Country:US
Mailing Address - Phone:360-394-1350
Mailing Address - Fax:360-598-2783
Practice Address - Street 1:6968 NE ENETAI LANE
Practice Address - Street 2:
Practice Address - City:SUQUAMISH
Practice Address - State:WA
Practice Address - Zip Code:98392-5147
Practice Address - Country:US
Practice Address - Phone:360-394-1350
Practice Address - Fax:360-598-2783
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2023-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00044447207Q00000X
WAMD00044447207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2098825Medicaid
00A730240Medicare ID - Type Unspecified