Provider Demographics
NPI:1770775868
Name:LIZOTTE, THOMAS W JR (CPO)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:W
Last Name:LIZOTTE
Suffix:JR
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:FIRCREST
Mailing Address - State:WA
Mailing Address - Zip Code:98466-7316
Mailing Address - Country:US
Mailing Address - Phone:253-761-9255
Mailing Address - Fax:253-564-7747
Practice Address - Street 1:1901 S WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-1015
Practice Address - Country:US
Practice Address - Phone:253-761-9255
Practice Address - Fax:253-564-7747
Is Sole Proprietor?:No
Enumeration Date:2007-08-14
Last Update Date:2007-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOI00000335222Z00000X
WAPS00000355224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9036963Medicaid