=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720147614
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LANNY LLOYD SNODGRASS M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | MADIGAN ARMY MEDICAL CTR
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98431-1100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-968-3072
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7120 TURQUOISE DR SW
-----------------------------------------------------
City | LAKEWOOD
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98498-6431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-968-3072
-----------------------------------------------------
Fax | 253-968-2061
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | MD00025233
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------