Provider Demographics
NPI:1356863625
Name:LAKE, JOSHUA
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:
Last Name:LAKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1540 S LAKE GEORGE DR
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46545-4065
Mailing Address - Country:US
Mailing Address - Phone:574-520-3149
Mailing Address - Fax:
Practice Address - Street 1:1501 E 3RD ST
Practice Address - Street 2:
Practice Address - City:DELTA
Practice Address - State:CO
Practice Address - Zip Code:81416-2815
Practice Address - Country:US
Practice Address - Phone:970-874-7681
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-08
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INNA367500000X
CO0996084367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered