Healthcare Provider Details

I. General information

NPI: 1740663228
Provider Name (Legal Business Name): NICHOLAS RATHJEN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2015
Last Update Date: 10/05/2021
Certification Date: 10/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MADIGAN ARMY MEDICAL CENTER FAMILY MEDICINE
TACOMA WA
98431-5650
US

IV. Provider business mailing address

MADIGAN ARMY MEDICAL CENTER 9040 JACKSON AVE
TACOMA WA
98431-0001
US

V. Phone/Fax

Practice location:
  • Phone: 253-968-0758
  • Fax:
Mailing address:
  • Phone: 210-875-7551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number77299
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: