Healthcare Provider Details

I. General information

NPI: 1376289819
Provider Name (Legal Business Name): KEVIN LACTAOEN RUARO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2022
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16110 8TH AVE SW STE A2
BURIEN WA
98166-2962
US

IV. Provider business mailing address

16110 8TH AVE SW STE A2
BURIEN WA
98166-2962
US

V. Phone/Fax

Practice location:
  • Phone: 206-242-8280
  • Fax: 206-242-8302
Mailing address:
  • Phone: 206-242-8280
  • Fax: 206-242-8302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD.MD.70097661
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR79503
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number77897
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: