Provider Demographics
NPI:1417992280
Name:LEWIS, LAURA FLICK (PA)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:FLICK
Last Name:LEWIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:LAURA
Other - Middle Name:A
Other - Last Name:FLICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:404 YAUGER WAY SW
Mailing Address - Street 2:SUITE 100
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-8660
Mailing Address - Country:US
Mailing Address - Phone:360-786-8990
Mailing Address - Fax:
Practice Address - Street 1:9040 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431-8660
Practice Address - Country:US
Practice Address - Phone:253-968-1790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10004699363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8479867Medicaid
WA8871164Medicare PIN
WAQ26353Medicare UPIN