Provider Demographics
NPI:1992488118
Name:ZAK, KAYLEE DEEN (PA-C)
Entity type:Individual
Prefix:
First Name:KAYLEE
Middle Name:DEEN
Last Name:ZAK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4659 SE CAVALRY WAY
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98367-8019
Mailing Address - Country:US
Mailing Address - Phone:360-337-9221
Mailing Address - Fax:
Practice Address - Street 1:463 TREMONT ST W STE 200
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-3743
Practice Address - Country:US
Practice Address - Phone:360-876-2434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-14
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WA61614976363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program