Provider Demographics
NPI:1972798122
Name:LY, KIM (DO)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:LY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2930 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-3832
Mailing Address - Country:US
Mailing Address - Phone:425-261-1692
Mailing Address - Fax:
Practice Address - Street 1:2930 MAPLE ST
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-3832
Practice Address - Country:US
Practice Address - Phone:425-261-1692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-11
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A7092207R00000X
WAOP00001825207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H02147Medicare UPIN