Healthcare Provider Details

I. General information

NPI: 1295416741
Provider Name (Legal Business Name): NISHANT GAUTAM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2023
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1718 E KESSLER BLVD
LONGVIEW WA
98632-1842
US

IV. Provider business mailing address

4864 JACKSON ST
MONROE LA
71202-6400
US

V. Phone/Fax

Practice location:
  • Phone: 360-747-5800
  • Fax: 360-575-3846
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD70045885
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: