Provider Demographics
NPI:1932892767
Name:LAKE, SERAWET
Entity Type:Individual
Prefix:
First Name:SERAWET
Middle Name:
Last Name:LAKE
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 1:13917 HEYWOOD DR
Mailing Address - Street 2:
Mailing Address - City:PFLUGERVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:78660-6125
Mailing Address - Country:US
Mailing Address - Phone:512-785-9487
Mailing Address - Fax:
Practice Address - Street 1:13917 HEYWOOD DR
Practice Address - Street 2:
Practice Address - City:PFLUGERVILLE
Practice Address - State:TX
Practice Address - Zip Code:78660-6125
Practice Address - Country:US
Practice Address - Phone:512-785-9487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-29
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX36572791343800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343800000XTransportation ServicesSecured Medical Transport (VAN)