=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780062034
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMANDA L. LUGO PAC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/07/2015
-----------------------------------------------------
Last Update Date | 01/05/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2820 GRIFFIN AVE STE 210
-----------------------------------------------------
City | ENUMCLAW
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98022-2373
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-825-7500
-----------------------------------------------------
Fax | 360-825-3370
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2820 GRIFFIN AVE STE 210
-----------------------------------------------------
City | ENUMCLAW
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98022-2373
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 360-825-7500
-----------------------------------------------------
Fax | 360-825-3370
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | PA70012203
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------