Provider Demographics
NPI:1891902458
Name:LAKESIDE FAMILY PHYSICIANS
Entity Type:Organization
Organization Name:LAKESIDE FAMILY PHYSICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:TUTTLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-369-1342
Mailing Address - Street 1:3719 W ANTHEM WAY STE 102
Mailing Address - Street 2:
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086-0477
Mailing Address - Country:US
Mailing Address - Phone:623-232-0082
Mailing Address - Fax:623-440-0501
Practice Address - Street 1:390 E SUNSET WAY
Practice Address - Street 2:
Practice Address - City:ISSAQUAH
Practice Address - State:WA
Practice Address - Zip Code:98027-3441
Practice Address - Country:US
Practice Address - Phone:425-369-1342
Practice Address - Fax:425-395-0245
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8858585Medicare ID - Type Unspecified