Provider Demographics
NPI:1023215514
Name:TOTEM LAKE FAMILY MEDICINE, PLLC
Entity Type:Organization
Organization Name:TOTEM LAKE FAMILY MEDICINE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:Y
Authorized Official - Last Name:MIYAUCHI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-899-5200
Mailing Address - Street 1:11800 NE 128TH ST
Mailing Address - Street 2:STE. 560
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-7208
Mailing Address - Country:US
Mailing Address - Phone:425-899-5200
Mailing Address - Fax:425-285-3108
Practice Address - Street 1:11800 NE 128TH ST
Practice Address - Street 2:STE, 560
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-7208
Practice Address - Country:US
Practice Address - Phone:425-899-5200
Practice Address - Fax:425-285-3108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-28
Last Update Date:2012-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WABUS14337207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty