Basic Information
| Provider Information | |||||||||
| NPI: | 1700189479 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ENSLIN | ||||||||
| FirstName: | LUCUS | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6400 SOUTHCENTER BLVD | ||||||||
| Address2: | |||||||||
| City: | TUKWILA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981882547 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2069012000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4200 STONE WAY N | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981037431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064613707 | ||||||||
| FaxNumber: | 2066322437 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2010 | ||||||||
| LastUpdateDate: | 04/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN61260852 | WA | N | Nursing Service Providers | Registered Nurse | 363L00000X | CNP01712 | NM | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | CNP-01712 | NM | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP2300X | AP61260884 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 84100079-EFF 12/1/14 | 05 | NM | MEDICAID | P01422156/DV3487 | 01 | NM | RAILROAD MEDICARE-ALBUQUERQUE | OTHER | 84100079 | 05 | NM | MEDICAID |