Provider Demographics
NPI:1427113331
Name:LAKE, CARTER A (PT)
Entity type:Individual
Prefix:
First Name:CARTER
Middle Name:A
Last Name:LAKE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:824 W LEWIS ST STE 204
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-5561
Mailing Address - Country:US
Mailing Address - Phone:509-544-0265
Mailing Address - Fax:509-544-0304
Practice Address - Street 1:1020 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MILTON FREEWATER
Practice Address - State:OR
Practice Address - Zip Code:97862-1534
Practice Address - Country:US
Practice Address - Phone:509-588-2924
Practice Address - Fax:509-588-4564
Is Sole Proprietor?:No
Enumeration Date:2006-12-22
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4916225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR269798Medicaid
WA0196934OtherDEPT LABOR & INDUSTRIES
WAG8866799Medicare PIN
ORR131666Medicare PIN