Provider Demographics
NPI:1245406032
Name:LAKE TAPPS FAMILY MEDICINE, PLLC
Entity Type:Organization
Organization Name:LAKE TAPPS FAMILY MEDICINE, PLLC
Other - Org Name:LAKE TAPPS FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:LILA
Authorized Official - Middle Name:MAUREEN
Authorized Official - Last Name:DAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD 00036049 WA
Authorized Official - Phone:253-862-8001
Mailing Address - Street 1:3920 W TAPPS DR E
Mailing Address - Street 2:
Mailing Address - City:LAKE TAPPS
Mailing Address - State:WA
Mailing Address - Zip Code:98391-9176
Mailing Address - Country:US
Mailing Address - Phone:253-862-8001
Mailing Address - Fax:253-826-4792
Practice Address - Street 1:3920 W TAPPS DR E
Practice Address - Street 2:
Practice Address - City:LAKE TAPPS
Practice Address - State:WA
Practice Address - Zip Code:98391-9176
Practice Address - Country:US
Practice Address - Phone:253-862-8001
Practice Address - Fax:253-826-4792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-01
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00036049207Q00000X
WAMD00009217207Q00000X
WAPA10005138363A00000X
WAPA10005081363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB17175Medicare PIN