Provider Demographics
NPI:1619385598
Name:ROLES, LAUREN (MD)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:ROLES
Suffix:
Gender:F
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:PO BOX 4825
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-4825
Mailing Address - Country:US
Mailing Address - Phone:360-882-2778
Mailing Address - Fax:
Practice Address - Street 1:7809 NE VANCOUVER PLAZA DR STE 110
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662
Practice Address - Country:US
Practice Address - Phone:360-882-2778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-23
Last Update Date:2019-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60951172207R00000X, 207RG0300X
ORFE184720207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2089353Medicaid