Healthcare Provider Details

I. General information

NPI: 1366835191
Provider Name (Legal Business Name): NICHOLAS K. MOLBY DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2015
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9040 JACKSON AVE DEPARTMENT OF FAMILY MEDICINE / SPORTS MEDICINE
TACOMA WA
98431
US

IV. Provider business mailing address

9040 JACKSON AVE DEPARTMENT OF FAMILY MEDICINE / SPORTS MEDICINE
TACOMA WA
98431
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-6287
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberOP61284760
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: