Provider Demographics
NPI:1477586535
Name:LAFAVOR, ROGER C (PAC)
Entity Type:Individual
Prefix:MR
First Name:ROGER
Middle Name:C
Last Name:LAFAVOR
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 MADISON ST
Mailing Address - Street 2:SUITE 901
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-1172
Mailing Address - Country:US
Mailing Address - Phone:206-226-4810
Mailing Address - Fax:206-264-8689
Practice Address - Street 1:601 BROADWAY
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-5330
Practice Address - Country:US
Practice Address - Phone:206-386-2600
Practice Address - Fax:206-622-1644
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10002191363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAR89576Medicare UPIN
WA000108620Medicare ID - Type Unspecified