Healthcare Provider Details

I. General information

NPI: 1447344528
Provider Name (Legal Business Name): WYLIE NICHOLAS VRACIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 05/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 NORTH MAIN STREET
COUPEVILLE WA
98239
US

IV. Provider business mailing address

PO BOX 1440
COUPEVILLE WA
98239-1440
US

V. Phone/Fax

Practice location:
  • Phone: 360-678-6576
  • Fax: 360-678-3970
Mailing address:
  • Phone: 360-678-6576
  • Fax: 360-678-3970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD00020146
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: