Basic Information
Provider Information | |||||||||
NPI: | 1770694713 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LAKEWOOD PEDIATRIC ASSOCIATES, PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 7424 BRIDGEPORT WAY W | ||||||||
Address2: | STE 103 | ||||||||
City: | LAKEWOOD | ||||||||
State: | WA | ||||||||
PostalCode: | 98499 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2535812111 | ||||||||
FaxNumber: | 2535817479 | ||||||||
Practice Location | |||||||||
Address1: | 7424 BRIDGEPORT WAY W | ||||||||
Address2: | STE 103 | ||||||||
City: | LAKEWOOD | ||||||||
State: | WA | ||||||||
PostalCode: | 98499 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2535812111 | ||||||||
FaxNumber: | 2535817479 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2006 | ||||||||
LastUpdateDate: | 04/26/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TAN | ||||||||
AuthorizedOfficialFirstName: | DARRYL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
AuthorizedOfficialTelephone: | 2535812111 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 7093628 | 05 | WA |   | MEDICAID | 8925744 | 01 | WA | PRACTICE CRIME VICTIMS # | OTHER | 0187382 | 01 | WA | PRACTICE L&I NUMBER | OTHER |