Provider Demographics
NPI:1679646848
Name:LACLERGUE, EDWARD GREGORY (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:GREGORY
Last Name:LACLERGUE
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 1:5130 CORPORATE CENTER CT SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-5957
Mailing Address - Country:US
Mailing Address - Phone:360-413-8600
Mailing Address - Fax:360-413-8822
Practice Address - Street 1:5130 CORPORATE CENTER CT SE
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-5957
Practice Address - Country:US
Practice Address - Phone:360-413-8600
Practice Address - Fax:360-413-8822
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00014428207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8216004Medicaid
WA1679646848OtherNPI
WA1679646848OtherNPI
WA8216004Medicaid
WAA09490Medicare UPIN