Healthcare Provider Details

I. General information

NPI: 1649912452
Provider Name (Legal Business Name): NATHAN DANIEL LICKTEIG DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2022
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1959 NE PACIFIC ST
SEATTLE WA
98195-0001
US

IV. Provider business mailing address

MSC08 4640 1 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131-0001
US

V. Phone/Fax

Practice location:
  • Phone: 206-543-1140
  • Fax:
Mailing address:
  • Phone: 505-272-4814
  • Fax: 505-272-0240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZB0001X
TaxonomyBlood Banking & Transfusion Medicine Physician
License NumberDO.OP.70077130
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: