Basic Information
Provider Information | |||||||||
NPI: | 1538329222 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LAKE | ||||||||
FirstName: | YASMIN | ||||||||
MiddleName: | NATASHA | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LAKE | ||||||||
OtherFirstName: | NATASHA | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 840853 | ||||||||
Address2: |   | ||||||||
City: | DALLAS | ||||||||
State: | TX | ||||||||
PostalCode: | 752840853 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9722331999 | ||||||||
FaxNumber: | 9722333666 | ||||||||
Practice Location | |||||||||
Address1: | 1500 CITYWEST BLVD | ||||||||
Address2: | STE. 300 | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 77042 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7136204000 | ||||||||
FaxNumber: | 7134584229 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/16/2008 | ||||||||
LastUpdateDate: | 06/04/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | BP20030297 | TX | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207L00000X | N8534 | TX | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 287533802 | 05 | TX |   | MEDICAID | 281533801 | 05 | TX |   | MEDICAID | P01746231 | 01 | TX | RR MEDICARE | OTHER | 8W9814 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER |