Provider Demographics
NPI:1659908622
Name:NICACIO, DOMINIC
Entity Type:Individual
Prefix:
First Name:DOMINIC
Middle Name:
Last Name:NICACIO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:932 NE 147TH ST
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98155-7050
Mailing Address - Country:US
Mailing Address - Phone:206-612-3320
Mailing Address - Fax:
Practice Address - Street 1:1000 BLYTHE BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5812
Practice Address - Country:US
Practice Address - Phone:704-355-3181
Practice Address - Fax:704-355-7047
Is Sole Proprietor?:No
Enumeration Date:2020-03-26
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAMD61405669207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program