Provider Demographics
NPI:1164619557
Name:LOCKNANE ATHLETIC MEDICINE LLC
Entity Type:Organization
Organization Name:LOCKNANE ATHLETIC MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:D
Authorized Official - Last Name:LOCKNANE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-368-4242
Mailing Address - Street 1:18518 BOTHELL WAY NE STE C
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-1927
Mailing Address - Country:US
Mailing Address - Phone:425-368-4242
Mailing Address - Fax:425-368-4243
Practice Address - Street 1:18518 BOTHELL WAY NE STE C
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-1927
Practice Address - Country:US
Practice Address - Phone:425-368-4242
Practice Address - Fax:425-368-4243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-28
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00036179261QM2500X, 261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8858161Medicare PIN