Provider Demographics
NPI:1891832242
Name:LAKE, BYRON FISK (MD)
Entity type:Individual
Prefix:
First Name:BYRON
Middle Name:FISK
Last Name:LAKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:300 SIERRA COLLEGE DR STE 170
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5083
Mailing Address - Country:US
Mailing Address - Phone:530-273-4376
Mailing Address - Fax:530-273-6426
Practice Address - Street 1:300 SIERRA COLLEGE DR STE 170
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5083
Practice Address - Country:US
Practice Address - Phone:530-273-4376
Practice Address - Fax:530-273-6426
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG58831207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE25236Medicare UPIN