Provider Demographics
NPI:1437187598
Name:NICHOLLS, STEPHEN (MD)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:NICHOLLS
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 1:600 BROADWAY 112
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98122-5381
Mailing Address - Country:US
Mailing Address - Phone:206-420-3119
Mailing Address - Fax:206-453-5912
Practice Address - Street 1:200 NE MOTHER JOSEPH PL
Practice Address - Street 2:SUITE 330
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-3299
Practice Address - Country:US
Practice Address - Phone:360-514-1854
Practice Address - Fax:360-514-6063
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2016-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA23966174400000X
WAMD000239662086S0129X
PAMD03825IL2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8105322Medicaid
WAG8887857Medicare PIN
PA501844FLTMedicare PIN
WA8105322Medicaid
PA0014958600004Medicare PIN