Healthcare Provider Details

I. General information

NPI: 1255108742
Provider Name (Legal Business Name): LAUREN DYKE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2023
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1112 S CUSHMAN AVE
TACOMA WA
98405-3631
US

IV. Provider business mailing address

PO BOX 34703
SEATTLE WA
98124-1703
US

V. Phone/Fax

Practice location:
  • Phone: 253-593-2144
  • Fax: 253-346-6725
Mailing address:
  • Phone: 253-681-6626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61526257
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: