Healthcare Provider Details

I. General information

NPI: 1568570257
Provider Name (Legal Business Name): GARY WAYNE NICKEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 07/08/2007
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 NumberMD00016939
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: