Healthcare Provider Details

I. General information

NPI: 1467665893
Provider Name (Legal Business Name): NIKOLAY A. USOLTSEV M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 08/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1321 COLBY AVE
EVERETT WA
98201-1665
US

IV. Provider business mailing address

10 COMMERCE DR
NEW ROCHELLE NY
10801-5253
US

V. Phone/Fax

Practice location:
  • Phone: 715-387-5511
  • Fax:
Mailing address:
  • Phone: 425-404-5352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number53068
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number60339708
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: