Provider Demographics
NPI:1700860756
Name:LAKE, ANNA (MD)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:
Last Name:LAKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1 UNIVERSITY OF NEW MEXICO
Mailing Address - Street 2:MSC06 3870
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87131-0001
Mailing Address - Country:US
Mailing Address - Phone:505-277-3136
Mailing Address - Fax:505-277-2020
Practice Address - Street 1:1 UNIVERSITY OF NEW MEXICO
Practice Address - Street 2:MSC06 3870
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-0001
Practice Address - Country:US
Practice Address - Phone:505-277-3136
Practice Address - Fax:505-277-2020
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2016-11-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NM91236207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM20007Medicaid
F88934Medicare UPIN