Healthcare Provider Details

I. General information

NPI: 1952109803
Provider Name (Legal Business Name): LAUREN RACHELLE BAZE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MS. LAUREN RACHELLE OMDAHL

II. Dates (important events)

Enumeration Date: 03/06/2025
Last Update Date: 11/25/2025
Certification Date: 11/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2021 K ST NW STE 615
WASHINGTON DC
20006-1066
US

IV. Provider business mailing address

2021 K ST NW STE 615
WASHINGTON DC
20006-1066
US

V. Phone/Fax

Practice location:
  • Phone: 202-808-8295
  • Fax: 202-808-8296
Mailing address:
  • Phone: 202-808-8295
  • Fax: 202-808-8296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110010718
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA200002164
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: