Provider Demographics
NPI:1467483628
Name:BOURDEAU, LEE MASON (MD)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:MASON
Last Name:BOURDEAU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7440 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98408-7117
Mailing Address - Country:US
Mailing Address - Phone:253-475-0511
Mailing Address - Fax:253-475-7440
Practice Address - Street 1:7440 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98408-7117
Practice Address - Country:US
Practice Address - Phone:253-475-0511
Practice Address - Fax:253-475-7440
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00013784208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8168650Medicaid
001059225Medicare ID - Type Unspecified
WA8168650Medicaid