Provider Demographics
NPI:1164544953
Name:WEBER, NICHOLAS KEITH (MD)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:KEITH
Last Name:WEBER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 LILLY RD NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506
Mailing Address - Country:US
Mailing Address - Phone:360-413-8250
Mailing Address - Fax:360-413-8830
Practice Address - Street 1:209 LILLY RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5030
Practice Address - Country:US
Practice Address - Phone:360-413-8250
Practice Address - Fax:360-413-8830
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60445962207R00000X, 207RG0100X, 207RG0100X
MN105425207RG0100X
MN54636207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA326227OtherSTATE L&I
WAG8930736Medicare PIN
MN100000934Medicare PIN