Provider Demographics
NPI:1255795639
Name:LIO, JEFFREY KEN (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:KEN
Last Name:LIO
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 1:1515 TACOMA AVE S APT 304
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98402-1823
Mailing Address - Country:US
Mailing Address - Phone:858-603-3680
Mailing Address - Fax:
Practice Address - Street 1:401 15TH AVE SE
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3715
Practice Address - Country:US
Practice Address - Phone:253-697-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-11
Last Update Date:2021-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WA60943937207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program