Basic Information
| Provider Information | |||||||||
| NPI: | 1437187598 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | NICHOLLS | ||||||||
| FirstName: | STEPHEN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 600 BROADWAY 112 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981225381 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064203119 | ||||||||
| FaxNumber: | 2064535912 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 NE MOTHER JOSEPH PL | ||||||||
| Address2: | SUITE 330 | ||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986643299 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605141854 | ||||||||
| FaxNumber: | 3605146063 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2006 | ||||||||
| LastUpdateDate: | 09/30/2016 | ||||||||
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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 | 174400000X | 23966 | WA | N | Other Service Providers | Specialist | 2086S0129X | MD00023966 | WA | Y | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 2086S0129X | MD03825IL | PA | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery |
ID Information
| ID | Type | State | Issuer | Description | 8105322 | 05 | WA | MEDICAID |