Provider Demographics
NPI:1427069889
Name:LAKE, JACK F (PA-C)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:F
Last Name:LAKE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2748 MILTON WAY
Mailing Address - Street 2:STE 101
Mailing Address - City:MILTON
Mailing Address - State:WA
Mailing Address - Zip Code:98354-9382
Mailing Address - Country:US
Mailing Address - Phone:253-922-5262
Mailing Address - Fax:253-922-5299
Practice Address - Street 1:2748 MILTON WAY
Practice Address - Street 2:STE 101
Practice Address - City:MILTON
Practice Address - State:WA
Practice Address - Zip Code:98354-9382
Practice Address - Country:US
Practice Address - Phone:253-922-5262
Practice Address - Fax:253-922-5299
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2010-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10001841363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP00153517OtherRAILROAD
WA0186925OtherSTATE L&I
WA8940030OtherSTATE CRIME VICTIMS
WA8401788Medicaid
WA8401788Medicaid
WAG8807175Medicare PIN