Basic Information
| Provider Information | |||||||||
| NPI: | 1942292875 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | LAKE WASHINGTON VASCULAR PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 94732 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981247032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254531772 | ||||||||
| FaxNumber: | 4254530603 | ||||||||
| Practice Location | |||||||||
| Address1: | 1135 116TH AVE NE STE 305 | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980044623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4254531772 | ||||||||
| FaxNumber: | 4254530603 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2005 | ||||||||
| LastUpdateDate: | 02/25/2015 | ||||||||
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| AuthorizedOfficialLastName: | PEPPER | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER, PLLC | ||||||||
| AuthorizedOfficialTelephone: | 4254531772 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 7105083 | 05 | WA | MEDICAID | CH9340 | 01 | WA | RR MEDICARE | OTHER |