NPIMap

Individual provider Active NPI

Kenneth Wayne Kooser, M.D.

  • Family Medicine Physician
  • Lacey, WA
National Provider Identifier
1306920772
Registry record updated Jun 16, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
MD60320788 Issued in WA
Practice address
4800 College St SE
Lacey, WA 98503-4389
Phone
(360) 486-2900
NPI assigned
Oct 24, 2006
Last updated
Jun 16, 2021By the provider in NPPES
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Jun 16, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X MD60320788 WA Primary

Addresses

Primary practice location

4800 College St SE
Lacey, WA 98503-4389

Mailing address

PO Box 3360
Portland, OR 97208-3360
Phone (866) 366-2983

Other identifiers 1

IdentifierTypeStateIssuer
1306920772MedicaidUT

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address kkooser253569@wm.providencedirect.org Direct

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in WA
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20130604000722 WA Practitioner - Family Practice 1355533076 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
University of Washington School of Medicine, 1999
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices

Practice addresses (Care Compare)

1620 Cooper Point Rd SW
Olympia, WA 98502-5736
Phone (306) 486-6710

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal of skin lesions1-10
Removal or shaving of skin growth1-10
Skin biopsy1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
MD60320788WAMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Providence Health & Services Washington Family Medicine CurrentSince Aug 1, 2016 Accepting new patients
Providence Health & Services - Washington CurrentSince Aug 16, 2016 Accepting new patients

Locations

1018 Capitol Way S
Ste 300
Olympia, WA 98501
Phone (360) 486-6508

1620 Cooper Point Rd SW
Olympia, WA 98502
Phone (360) 486-6710

4800 College St SE
Olympia, WA 98503
Phone (360) 456-7575

525 Lilly Rd NE
Olympia, WA 98506
Phone (360) 413-8550

18313 Paulson St SW
Ste A
Rochester, WA 98579
Phone (360) 273-8818

Interoperability endpoints

  • Direct secure messaging: kkooser253569@wm.providencedirect.org

Organizations & group practices 2

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 4

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1161648000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1623801600000",
    "number": "1306920772",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 3360",
            "city": "PORTLAND",
            "state": "OR",
            "postal_code": "972083360",
            "telephone_number": "866-366-2983"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4800 COLLEGE ST SE",
            "city": "LACEY",
            "state": "WA",
            "postal_code": "985034389",
            "telephone_number": "360-486-2900"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "KOOSER",
        "first_name": "KENNETH",
        "middle_name": "WAYNE",
        "name_prefix": "Dr.",
        "credential": "M.D.",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-10-24",
        "last_updated": "2021-06-16",
        "certification_date": "2021-06-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "WA",
            "license": "MD60320788",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "1306920772",
            "state": "UT"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "kkooser253569@wm.providencedirect.org",
            "affiliation": "N",
            "use": "DIRECT",
            "useDescription": "Direct",
            "address_1": "4800 College St SE",
            "city": "Lacey",
            "state": "WA",
            "country_code": "US",
            "postal_code": "985034389",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Lacey, WA

Sources for this page

Verify at the official NPI Registry.