Provider Demographics
NPI:1497294557
Name:SCHOULTZ, NILS GIBSON (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:NILS
Middle Name:GIBSON
Last Name:SCHOULTZ
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4455 CORDATA PKWY
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98226-8037
Mailing Address - Country:US
Mailing Address - Phone:360-671-3225
Mailing Address - Fax:
Practice Address - Street 1:4455 CORDATA PKWY
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98226-8037
Practice Address - Country:US
Practice Address - Phone:360-671-3225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-21
Last Update Date:2017-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60714204363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant