Provider Demographics
NPI:1093817546
Name:LOMOTAN, CHRISTINE AGBAYANI (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:AGBAYANI
Last Name:LOMOTAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 POTTERY AVE
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98366-3711
Mailing Address - Country:US
Mailing Address - Phone:360-895-5000
Mailing Address - Fax:
Practice Address - Street 1:1400 POTTERY AVE
Practice Address - Street 2:
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366-3711
Practice Address - Country:US
Practice Address - Phone:360-895-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-04
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00030451207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0255580OtherSTATE L & I
WA0129072OtherSTATE L & I
WA0224704OtherSTATE L & I
WA0227446OtherSTATE L & I
WAMD30451OtherWA STATE LICENSE
WAG8869640Medicare PIN
WAG8867961Medicare PIN
WA0224704OtherSTATE L & I