Provider Demographics
NPI:1710094156
Name:PERRIN, LAURENCE E (MD)
Entity Type:Individual
Prefix:
First Name:LAURENCE
Middle Name:E
Last Name:PERRIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 BLACK HILLS LN SW STE C
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-8144
Mailing Address - Country:US
Mailing Address - Phone:360-754-3380
Mailing Address - Fax:
Practice Address - Street 1:406 BLACK HILLS LN SW STE C
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-8144
Practice Address - Country:US
Practice Address - Phone:360-754-3380
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00020730208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1095413Medicaid
WA1095413Medicaid
WAA38539Medicare UPIN