Provider Demographics
NPI:1548393424
Name:LAYBOURN, LOREN EARNEST (MD)
Entity Type:Individual
Prefix:DR
First Name:LOREN
Middle Name:EARNEST
Last Name:LAYBOURN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3417 ENSIGN RD NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98507-5075
Mailing Address - Country:US
Mailing Address - Phone:360-493-4609
Mailing Address - Fax:360-493-4603
Practice Address - Street 1:1108 BASICH BLVD
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:WA
Practice Address - Zip Code:98520-1066
Practice Address - Country:US
Practice Address - Phone:360-533-0400
Practice Address - Fax:360-533-5633
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000468442085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8476897Medicaid
WA8476897Medicaid
WAI73616Medicare UPIN