Provider Demographics
NPI:1487157020
Name:KY, PRIM PREY (PA-C)
Entity type:Individual
Prefix:
First Name:PRIM
Middle Name:PREY
Last Name:KY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:PRIM
Other - Middle Name:PREY
Other - Last Name:LY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 2928
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-2928
Mailing Address - Country:US
Mailing Address - Phone:425-207-5155
Mailing Address - Fax:
Practice Address - Street 1:1350 MARVIN RD NE STE D
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98516-3877
Practice Address - Country:US
Practice Address - Phone:888-227-3312
Practice Address - Fax:360-413-6509
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-09
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60763223363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1922139534Medicaid
WA1831253368Medicaid