Provider Demographics
NPI:1942292875
Name:LAKE WASHINGTON VASCULAR PLLC
Entity Type:Organization
Organization Name:LAKE WASHINGTON VASCULAR PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER, PLLC
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:PEPPER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:425-453-1772
Mailing Address - Street 1:PO BOX 94732
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-7032
Mailing Address - Country:US
Mailing Address - Phone:425-453-1772
Mailing Address - Fax:425-453-0603
Practice Address - Street 1:1135 116TH AVE NE STE 305
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-4623
Practice Address - Country:US
Practice Address - Phone:425-453-1772
Practice Address - Fax:425-453-0603
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-17
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7105083Medicaid
WACH9340OtherRR MEDICARE
WAGAB18684Medicare PIN