Provider Demographics
NPI:1790740686
Name:MARLOW, LEA (MD)
Entity Type:Individual
Prefix:DR
First Name:LEA
Middle Name:
Last Name:MARLOW
Suffix:
Gender:F
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:PO BOX N
Mailing Address - Street 2:
Mailing Address - City:ILWACO
Mailing Address - State:WA
Mailing Address - Zip Code:98624-9137
Mailing Address - Country:US
Mailing Address - Phone:360-642-6498
Mailing Address - Fax:360-642-0114
Practice Address - Street 1:167 1ST AVE N
Practice Address - Street 2:PO BOX N
Practice Address - City:ILWACO
Practice Address - State:WA
Practice Address - Zip Code:98624-9137
Practice Address - Country:US
Practice Address - Phone:360-642-6498
Practice Address - Fax:360-642-0114
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA063370207Q00000X
WAMD60202294207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA314276978AMedicaid
SCGA1010Medicaid
F30512Medicare UPIN
SCGA1010Medicaid