Provider Demographics
NPI:1407858665
Name:KAGEYAMA, NICOLE PREVO (MD)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:PREVO
Last Name:KAGEYAMA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 112TH AVE NE
Mailing Address - Street 2:SUITE C-187
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98007
Mailing Address - Country:US
Mailing Address - Phone:425-457-7900
Mailing Address - Fax:425-457-7499
Practice Address - Street 1:1412 SW 43RD ST STE 205
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-4803
Practice Address - Country:US
Practice Address - Phone:425-264-0660
Practice Address - Fax:425-264-0601
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00046078207ND0900X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP00301940OtherRAILROAD MEDICARE
H64679Medicare UPIN
WAG8858890Medicare PIN