Provider Demographics
NPI:1700471547
Name:GAYTON, LANCE VICTOR
Entity Type:Individual
Prefix:
First Name:LANCE
Middle Name:VICTOR
Last Name:GAYTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 34703
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1703
Mailing Address - Country:US
Mailing Address - Phone:206-764-0502
Mailing Address - Fax:206-764-0516
Practice Address - Street 1:6221 NE FOURTH PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98661-7206
Practice Address - Country:US
Practice Address - Phone:206-472-8172
Practice Address - Fax:360-952-8641
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-03
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM0801X
WA261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)