Provider Demographics
NPI:1770694713
Name:LAKEWOOD PEDIATRIC ASSOCIATES, PLLC
Entity type:Organization
Organization Name:LAKEWOOD PEDIATRIC ASSOCIATES, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:
Authorized Official - Last Name:TAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:253-581-2111
Mailing Address - Street 1:7424 BRIDGEPORT WAY W
Mailing Address - Street 2:STE 103
Mailing Address - City:LAKEWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98499
Mailing Address - Country:US
Mailing Address - Phone:253-581-2111
Mailing Address - Fax:253-581-7479
Practice Address - Street 1:7424 BRIDGEPORT WAY W
Practice Address - Street 2:STE 103
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499
Practice Address - Country:US
Practice Address - Phone:253-581-2111
Practice Address - Fax:253-581-7479
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7093628Medicaid
WA8925744OtherPRACTICE CRIME VICTIMS #
WA0187382OtherPRACTICE L&I NUMBER