Healthcare Provider Details

I. General information

NPI: 1427311869
Provider Name (Legal Business Name): GARY W NICKEL, MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2012
Last Update Date: 06/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 N J ST SUITE A
TACOMA WA
98403-1984
US

IV. Provider business mailing address

222 N J ST SUITE A
TACOMA WA
98403-1984
US

V. Phone/Fax

Practice location:
  • Phone: 253-572-4664
  • Fax: 253-591-0097
Mailing address:
  • Phone: 253-572-4664
  • Fax: 253-591-0097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. GARY WAYNE NICKEL
Title or Position: PHYSICIAN
Credential: MD
Phone: 253-572-4664