Basic Information
| Provider Information | |||||||||
| NPI: | 1336464247 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KAWAGUCHI | ||||||||
| FirstName: | KRISTA | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3600 LIND AVE SW | ||||||||
| Address2: | SUITE 100 ATTN CREDENTIALING | ||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980574970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256902715 | ||||||||
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| Practice Location | |||||||||
| Address1: | 400 S 43RD ST | ||||||||
| Address2: | |||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980555714 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256565566 | ||||||||
| FaxNumber: | 4256565567 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/02/2010 | ||||||||
| LastUpdateDate: | 03/10/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | MD60299818 | WA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | G8944145 | 01 | WA | MEDICARE - VALLEY MEDICAL GROUP | OTHER | 2018894 | 05 | WA | MEDICAID |