Basic Information
| Provider Information | |||||||||
| NPI: | 1568777175 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ULLOM | ||||||||
| FirstName: | NATHAN | ||||||||
| MiddleName: | ALLEN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 E KINCAID ST | ||||||||
| Address2: | ATTN: CREDENTIALING | ||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982744127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604282500 | ||||||||
| FaxNumber: | 3604286485 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 E KINCAID ST | ||||||||
| Address2: | |||||||||
| City: | MOUNT VERNON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982744127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3608484120 | ||||||||
| FaxNumber: | 3604247945 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2010 | ||||||||
| LastUpdateDate: | 09/17/2013 | ||||||||
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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 | 213ES0103X | SC006241 | PA | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 213E00000X | PO60398534 | WA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | 213ES0103X | PO60398534 | WA | N | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
No ID Information.