Basic Information
| Provider Information | |||||||||
| NPI: | 1679693311 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIRKEGAARD | ||||||||
| FirstName: | LANCE | ||||||||
| MiddleName: | W. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1717 S J ST | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534266341 | ||||||||
| FaxNumber: | 2534266344 | ||||||||
| Practice Location | |||||||||
| Address1: | 1717 S J ST | ||||||||
| Address2: | |||||||||
| City: | TACOMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984054933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2534266341 | ||||||||
| FaxNumber: | 2534266344 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2007 | ||||||||
| LastUpdateDate: | 11/16/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD00026688 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0127104 | 01 | WA | STATE L&I | OTHER | 1054667 | 05 | WA | MEDICAID | 8902544 | 01 | WA | STATE CRIME VICTIMS | OTHER |