Healthcare Provider Details

I. General information

NPI: 1811499353
Provider Name (Legal Business Name): MATTHEW LAVOIE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2018
Last Update Date: 03/22/2024
Certification Date: 03/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 JACKSON AVE
JOINT BASE LEWIS MCCHORD WA
98431-1000
US

IV. Provider business mailing address

9040 JACKSON AVE
TACOMA WA
98431-1000
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-3866
  • Fax: 253-968-0624
Mailing address:
  • Phone: 253-968-0208
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number61529554
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: