Basic Information
| Provider Information | |||||||||
| NPI: | 1174572044 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAMBURRI | ||||||||
| FirstName: | NICHOLAS | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11108 CHENNAULT BEACH RD | ||||||||
| Address2: | #1021 | ||||||||
| City: | MUKILTEO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982754903 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1321 COLBY AVE | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982011665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4252612000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/09/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA10004831 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 8434011 | 05 | WA | MEDICAID |