Healthcare Provider Details

I. General information

NPI: 1770694713
Provider Name (Legal Business Name): LAKEWOOD PEDIATRIC ASSOCIATES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 04/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7424 BRIDGEPORT WAY W STE 103
LAKEWOOD WA
98499
US

IV. Provider business mailing address

7424 BRIDGEPORT WAY W STE 103
LAKEWOOD WA
98499
US

V. Phone/Fax

Practice location:
  • Phone: 253-581-2111
  • Fax: 253-581-7479
Mailing address:
  • Phone: 253-581-2111
  • Fax: 253-581-7479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DARRYL TAN
Title or Position: MANAGING PARTNER
Credential: M.D.
Phone: 253-581-2111