Healthcare Provider Details

I. General information

NPI: 1255601860
Provider Name (Legal Business Name): RAY M NICOLA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2012
Last Update Date: 01/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1959 NE PACIFIC ST RM H-681
SEATTLE WA
98195-7660
US

IV. Provider business mailing address

BOX 357660
SEATTLE WA
98195-7660
US

V. Phone/Fax

Practice location:
  • Phone: 206-221-6179
  • Fax:
Mailing address:
  • Phone: 206-221-6179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number00019048
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: