Basic Information
| Provider Information | |||||||||
| NPI: | 1497826424 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAKAN | ||||||||
| FirstName: | NIZAR | ||||||||
| MiddleName: | R. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5096 | ||||||||
| Address2: | |||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982275096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607382200 | ||||||||
| FaxNumber: | 3607525653 | ||||||||
| Practice Location | |||||||||
| Address1: | 4465 CORDATA PKWY | ||||||||
| Address2: | |||||||||
| City: | BELLINGHAM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982268037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607382200 | ||||||||
| FaxNumber: | 3607525653 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 10/04/2010 | ||||||||
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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 | 207N00000X | G40174 | CA | N | Allopathic & Osteopathic Physicians | Dermatology | 207N00000X | MD00021424 | WA | Y | Allopathic & Osteopathic Physicians | Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 1497826424 | 05 | WA | MEDICAID | 7017989 | 01 | WA | AETNA | OTHER | 4466MA | 01 | WA | REGENCE | OTHER | 00G401740 | 05 | CA | MEDICAID | 0229998 | 01 | WA | L&I AND CRIME VICTIMS | OTHER |