Provider Demographics
NPI:1467425330
Name:IVERSON, NICHOL T (MD)
Entity Type:Individual
Prefix:
First Name:NICHOL
Middle Name:T
Last Name:IVERSON
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 1:1701 3RD ST SE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98372-4511
Mailing Address - Country:US
Mailing Address - Phone:253-697-5767
Mailing Address - Fax:253-697-5682
Practice Address - Street 1:1701 3RD ST SE
Practice Address - Street 2:SUITE 300
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-4511
Practice Address - Country:US
Practice Address - Phone:253-697-5767
Practice Address - Fax:253-697-5682
Is Sole Proprietor?:No
Enumeration Date:2006-02-09
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00014336207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA193400000XOtherTAXONONMY
WA111661087OtherMEDICARE OTHER-INDIVIDUAL
WA1410802Medicaid
WACO3401OtherMEDICARE OTHER-GROUP
WA1410802Medicaid
WA111661087OtherMEDICARE OTHER-INDIVIDUAL