Healthcare Provider Details

I. General information

NPI: 1821651746
Provider Name (Legal Business Name): LAUREN WASHATKA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAUREN DOMINICK

II. Dates (important events)

Enumeration Date: 04/16/2019
Last Update Date: 07/31/2023
Certification Date: 07/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

806 S PONDEROSA ST
PAYSON AZ
85541-5541
US

IV. Provider business mailing address

806 S PONDEROSA ST
PAYSON AZ
85541-5541
US

V. Phone/Fax

Practice location:
  • Phone: 928-468-8603
  • Fax:
Mailing address:
  • Phone: 928-468-8603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number70506
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number70506
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: