Provider Demographics
NPI:1245416882
Name:ISSAQUAH PLASTIC SURGERY PLLC
Entity Type:Organization
Organization Name:ISSAQUAH PLASTIC SURGERY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:
Authorized Official - Last Name:LU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-392-8282
Mailing Address - Street 1:1505 NW GILMAN BLVD STE 4
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-5398
Mailing Address - Country:US
Mailing Address - Phone:425-392-8282
Mailing Address - Fax:
Practice Address - Street 1:1505 NW GILMAN BLVD STE 4
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-5398
Practice Address - Country:US
Practice Address - Phone:425-392-8282
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-14
Last Update Date:2008-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8856487Medicare PIN