Basic Information
| Provider Information | |||||||||
| NPI: | 1992764880 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FIDDA | ||||||||
| FirstName: | NISREEN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3941 | ||||||||
| Address2: | |||||||||
| City: | SEATTLE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 981243941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604597770 | ||||||||
| FaxNumber: | 3604594361 | ||||||||
| Practice Location | |||||||||
| Address1: | 3900 CAPITAL MALL DRIVE SW | ||||||||
| Address2: | |||||||||
| City: | OLYMPIA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607545858 | ||||||||
| FaxNumber: | 3609562574 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2006 | ||||||||
| LastUpdateDate: | 12/18/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | MD00044946 | WA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0102X | MD24504 | OR | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 203962 | 01 | WA | LABOR & INDUSTRIES | OTHER | 8412462 | 05 | WA | MEDICAID |