Healthcare Provider Details

I. General information

NPI: 1295023331
Provider Name (Legal Business Name): NICHOLAS FAWCETT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2011
Last Update Date: 12/03/2020
Certification Date: 12/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 S J ST
TACOMA WA
98405-4933
US

IV. Provider business mailing address

1717 S J ST
TACOMA WA
98405-4933
US

V. Phone/Fax

Practice location:
  • Phone: 844-364-2778
  • Fax: 253-426-6344
Mailing address:
  • Phone: 844-364-2778
  • Fax: 253-426-6344

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA-01527
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP60911360
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: