Provider Demographics
NPI:1407965148
Name:NALL, JOHN STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:STEPHEN
Last Name:NALL
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 1:908 E BURK RD
Mailing Address - Street 2:
Mailing Address - City:COLBERT
Mailing Address - State:WA
Mailing Address - Zip Code:99005
Mailing Address - Country:US
Mailing Address - Phone:509-468-8507
Mailing Address - Fax:
Practice Address - Street 1:9222 N NEWPORT HWY
Practice Address - Street 2:SUITE 1
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99218
Practice Address - Country:US
Practice Address - Phone:509-467-4545
Practice Address - Fax:509-467-2304
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00034910207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0133260OtherL&I
WA8252975Medicaid
WA8252975Medicaid
WAAB10289Medicare ID - Type Unspecified