Healthcare Provider Details

I. General information

NPI: 1205125820
Provider Name (Legal Business Name): LUIS NELSON ROMAN LANTIGUA-TATEM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2011
Last Update Date: 06/27/2025
Certification Date: 06/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

747 BROADWAY
SEATTLE WA
98122-4379
US

IV. Provider business mailing address

PO BOX 25608
SALT LAKE CITY UT
84125-0608
US

V. Phone/Fax

Practice location:
  • Phone: 206-215-2520
  • Fax: 206-386-3180
Mailing address:
  • Phone: 206-320-4476
  • Fax: 206-568-7043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberMD61545752
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberMD61545752
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: