Provider Demographics
NPI:1629021852
Name:STAFFORD, LYNDA BRADY (DO)
Entity Type:Individual
Prefix:
First Name:LYNDA
Middle Name:BRADY
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4001 HARRISON AVE NW
Mailing Address - Street 2:STE 101
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-5084
Mailing Address - Country:US
Mailing Address - Phone:360-704-2362
Mailing Address - Fax:360-350-1445
Practice Address - Street 1:319 E PIONEER AVE
Practice Address - Street 2:
Practice Address - City:MONTESANO
Practice Address - State:WA
Practice Address - Zip Code:98563-4601
Practice Address - Country:US
Practice Address - Phone:360-249-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00002036207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8449522Medicaid
WAG8900040Medicare PIN
WA8449522Medicaid