Healthcare Provider Details

I. General information

NPI: 1821662362
Provider Name (Legal Business Name): MICHAEL LYCAN LAT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2021
Last Update Date: 05/19/2021
Certification Date: 05/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8217 17TH ST SE
LAKE STEVENS WA
98258-3839
US

IV. Provider business mailing address

8217 17TH ST SE
LAKE STEVENS WA
98258-3839
US

V. Phone/Fax

Practice location:
  • Phone: 503-930-1828
  • Fax:
Mailing address:
  • Phone: 503-930-1828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberA160711532
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: