Provider Demographics
NPI:1740602929
Name:LILLY, HAROLD RYAN (LAC, EAMP)
Entity type:Individual
Prefix:MR
First Name:HAROLD
Middle Name:RYAN
Last Name:LILLY
Suffix:
Gender:M
Credentials:LAC, EAMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14500 JUANITA DR NE
Mailing Address - Street 2:G HALL 301
Mailing Address - City:KENMORE
Mailing Address - State:WA
Mailing Address - Zip Code:98028-4966
Mailing Address - Country:US
Mailing Address - Phone:425-780-6020
Mailing Address - Fax:
Practice Address - Street 1:10127 MAIN PL
Practice Address - Street 2:SUITE B
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-3402
Practice Address - Country:US
Practice Address - Phone:425-780-6020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-07
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC60392092171100000X
PAOM000165171100000X
MTMED-ACU-LIC-26569171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist