Healthcare Provider Details

I. General information

NPI: 1184990590
Provider Name (Legal Business Name): DOMINIC LEE VAN NIELEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2012
Last Update Date: 08/31/2023
Certification Date: 08/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19200 N KELSEY ST
MONROE WA
98272-1431
US

IV. Provider business mailing address

1100 PACIFIC AVE STE 300
EVERETT WA
98201-4261
US

V. Phone/Fax

Practice location:
  • Phone: 425-339-2433
  • Fax: 425-339-8237
Mailing address:
  • Phone: 425-339-2433
  • Fax: 425-339-8273

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberD94626
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License NumberMD61002589
License Number StateWA
# 3
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberMD61002589
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: