Provider Demographics
NPI:1023053857
Name:WARD, LYSA SUSANNE (MD)
Entity type:Individual
Prefix:
First Name:LYSA
Middle Name:SUSANNE
Last Name:WARD
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 1:505 S 336TH ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6328
Mailing Address - Country:US
Mailing Address - Phone:253-838-6180
Mailing Address - Fax:253-838-6418
Practice Address - Street 1:34515 9TH AVE S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6761
Practice Address - Country:US
Practice Address - Phone:253-838-9700
Practice Address - Fax:253-838-6418
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00040467207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0180224OtherLIWA
WA1186WAOtherBSWA
WA0171209OtherLIWA
WA2165WAOtherBSWA
WA2217WAOtherBSWA
WA0171208OtherLIWA
WA8288730Medicaid
WAG8853915Medicare PIN
WAP00251472Medicare PIN
WA1186WAOtherBSWA
WA0171209OtherLIWA