Provider Demographics
NPI:1922193317
Name:MYRE, LAURA ELLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:ELLEN
Last Name:MYRE
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 1:4515 MARTIN LUTHER KING JR. WAY SOUTH
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98108-2174
Mailing Address - Country:US
Mailing Address - Phone:206-320-5325
Mailing Address - Fax:206-320-5326
Practice Address - Street 1:4515 MARTIN LUTHER KING JR WAY SOUTH
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98108-2174
Practice Address - Country:US
Practice Address - Phone:206-320-5325
Practice Address - Fax:206-320-5326
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041878207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8373037Medicaid
E27869Medicare UPIN