Provider Demographics
NPI:1962508507
Name:VANDE VUSSE, LISA KAREN (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:KAREN
Last Name:VANDE VUSSE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:LISA
Other - Middle Name:KAREN
Other - Last Name:ERNST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 50095
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145-5095
Mailing Address - Country:US
Mailing Address - Phone:206-543-6420
Mailing Address - Fax:
Practice Address - Street 1:325 9TH AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-2420
Practice Address - Country:US
Practice Address - Phone:206-744-3241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60142363207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1962508507Medicaid
WA1962508507Medicaid