Provider Demographics
NPI:1487762506
Name:TENEYCK, LISA (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:TENEYCK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 S 336TH ST
Mailing Address - Street 2:SUITE 600
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-6328
Mailing Address - Country:US
Mailing Address - Phone:253-838-6180
Mailing Address - Fax:253-838-6418
Practice Address - Street 1:11315 BRIDGEPORT WAY SW
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:WA
Practice Address - Zip Code:98499-3004
Practice Address - Country:US
Practice Address - Phone:253-589-8700
Practice Address - Fax:253-581-6588
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAMD00048350207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0222147OtherLIWA
WA7554TEOtherBSWA
WA8484685Medicaid
WA7554TEOtherBSWA
WAG8865923Medicare PIN