Healthcare Provider Details

I. General information

NPI: 1467483628
Provider Name (Legal Business Name): LEE MASON BOURDEAU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 04/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7440 PACIFIC AVE
TACOMA WA
98408-7117
US

IV. Provider business mailing address

7440 PACIFIC AVE
TACOMA WA
98408-7117
US

V. Phone/Fax

Practice location:
  • Phone: 253-475-0511
  • Fax: 253-475-7440
Mailing address:
  • Phone: 253-475-0511
  • Fax: 253-475-7440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberMD00013784
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00013784
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: