Individual
JACK F LAKE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA-C
Contact information
Practice address
2748 MILTON WAY, STE 101, MILTON, WA 98354-9382
(253) 922-5262
(253) 922-5299
Mailing address
2748 MILTON WAY, STE 101, MILTON, WA 98354-9382
(253) 922-5262
(253) 922-5299
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA10001841
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0186925
STATE L&I
WA
05
—
8401788
—
WA
01
—
8940030
STATE CRIME VICTIMS
WA
01
—
P00153517
RAILROAD
WA
Enumeration date
08/11/2006
Last updated
11/16/2010
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