Provider Demographics
NPI:1003921701
Name:PEARSON, MICHAEL LANE (MD)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:LANE
Last Name:PEARSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12904 94TH AVE EAST
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373
Mailing Address - Country:US
Mailing Address - Phone:253-841-3999
Mailing Address - Fax:253-841-7311
Practice Address - Street 1:12904 94TH AVE EAST
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373
Practice Address - Country:US
Practice Address - Phone:253-841-3999
Practice Address - Fax:253-841-7311
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2012-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00014726208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1069103Medicaid
WA7200058Medicaid