=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649872680
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROCTOR PERSONAL MD, PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/13/2020
-----------------------------------------------------
Last Update Date | 10/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2517 N WASHINGTON ST
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98406-5841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-759-3586
-----------------------------------------------------
Fax | 253-759-5746
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2517 N WASHINGTON ST
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98406-5841
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-759-3586
-----------------------------------------------------
Fax | 253-759-5746
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN/OWNER
-----------------------------------------------------
Name | DR. LISA V HAMILL
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 253-759-3586
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------