Provider Demographics
NPI:1710955273
Name:WALKER, LISA K (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:K
Last Name:WALKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:K
Other - Last Name:WAGNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1501 PACIFIC AVE
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-3302
Mailing Address - Country:US
Mailing Address - Phone:253-680-6016
Mailing Address - Fax:
Practice Address - Street 1:1501 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98402-3302
Practice Address - Country:US
Practice Address - Phone:253-680-6016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO45580207Q00000X
WAMD60587860207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH45065Medicare PIN
H45065Medicare UPIN