Basic Information
| Provider Information | |||||||||
| NPI: | 1437457793 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LAINE | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | JUSTINE LEE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | O.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEE | ||||||||
| OtherFirstName: | MEGAN | ||||||||
| OtherMiddleName: | JUSTINE | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | O.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3925 159TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | REDMOND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980526309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252160550 | ||||||||
| FaxNumber: | 4252160551 | ||||||||
| Practice Location | |||||||||
| Address1: | 3925 159TH AVE NE | ||||||||
| Address2: | |||||||||
| City: | REDMOND | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980526309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252160550 | ||||||||
| FaxNumber: | 4252160551 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2011 | ||||||||
| LastUpdateDate: | 07/20/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 14672 | CA | N | Eye and Vision Services Providers | Optometrist | 152W00000X | 60629205 | WA | Y | Eye and Vision Services Providers | Optometrist |
No ID Information.