Provider Demographics
NPI:1124478870
Name:AGUILAR, LAURA LYNN (DO)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:LYNN
Last Name:AGUILAR
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:LYNN
Other - Last Name:PAIVA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3600 LIND AVE SW
Mailing Address - Street 2:SUITE 100 ATTN CREDENTIALING
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98057
Mailing Address - Country:US
Mailing Address - Phone:425-690-2715
Mailing Address - Fax:
Practice Address - Street 1:26458 MAPLE VALLEY BLACK DIAMOND RD SE
Practice Address - Street 2:
Practice Address - City:MAPLE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:98038
Practice Address - Country:US
Practice Address - Phone:425-690-3460
Practice Address - Fax:425-690-9460
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-14
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
WAOP60975529207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2143780Medicaid