1770694713 NPI number — LAKEWOOD PEDIATRIC ASSOCIATES, PLLC

Table of content: (NPI 1770694713)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770694713 NPI number — LAKEWOOD PEDIATRIC ASSOCIATES, PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAKEWOOD PEDIATRIC ASSOCIATES, PLLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1770694713
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/26/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7424 BRIDGEPORT WAY W
Provider Second Line Business Mailing Address:
STE 103
Provider Business Mailing Address City Name:
LAKEWOOD
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98499
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
253-581-2111
Provider Business Mailing Address Fax Number:
253-581-7479

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7424 BRIDGEPORT WAY W
Provider Second Line Business Practice Location Address:
STE 103
Provider Business Practice Location Address City Name:
LAKEWOOD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98499
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-581-2111
Provider Business Practice Location Address Fax Number:
253-581-7479
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
TAN
Authorized Official First Name:
DARRYL
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
253-581-2111

Provider Taxonomy Codes

  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7093628 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 8925744 . This is a "PRACTICE CRIME VICTIMS #" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".
  • Identifier: 0187382 . This is a "PRACTICE L&I NUMBER" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




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