Healthcare Provider Details

I. General information

NPI: 1083037287
Provider Name (Legal Business Name): MICHAEL NIEBERGALL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2014
Last Update Date: 01/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 N HIGHLANDS PKWY
TACOMA WA
98406-2116
US

IV. Provider business mailing address

5018 84TH AVE W
UNIVERSITY PLACE WA
98467-1824
US

V. Phone/Fax

Practice location:
  • Phone: 253-752-7112
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberP1 60231813
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: