Healthcare Provider Details

I. General information

NPI: 1407387186
Provider Name (Legal Business Name): JESSICA LAZAR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2017
Last Update Date: 12/18/2020
Certification Date: 12/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 LAKE ST
KENAI AK
99611-6937
US

IV. Provider business mailing address

903 32ND AVE E
SEATTLE WA
98112-3702
US

V. Phone/Fax

Practice location:
  • Phone: 907-714-4025
  • Fax: 844-412-3952
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number165745
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: