Healthcare Provider Details

I. General information

NPI: 1053604819
Provider Name (Legal Business Name): ADAM TODD NICKEL DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2011
Last Update Date: 09/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 N J ST
TACOMA WA
98403-1984
US

IV. Provider business mailing address

222 N J ST
TACOMA WA
98403-1984
US

V. Phone/Fax

Practice location:
  • Phone: 253-572-4664
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number58.003060
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License NumberOP60274656
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: