Healthcare Provider Details

I. General information

NPI: 1942292875
Provider Name (Legal Business Name): LAKE WASHINGTON VASCULAR PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2005
Last Update Date: 02/25/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1135 116TH AVE NE STE 305
BELLEVUE WA
98004-4623
US

IV. Provider business mailing address

PO BOX 94732
SEATTLE WA
98124-7032
US

V. Phone/Fax

Practice location:
  • Phone: 425-453-1772
  • Fax: 425-453-0603
Mailing address:
  • Phone: 425-453-1772
  • Fax: 425-453-0603

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: DANIEL PEPPER
Title or Position: MANAGING PARTNER, PLLC
Credential: MD
Phone: 425-453-1772