Provider Demographics
NPI:1700226180
Name:GUBLER, NICHOLAS (OD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:GUBLER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5813 TYRE DR
Mailing Address - Street 2:
Mailing Address - City:PASCO
Mailing Address - State:WA
Mailing Address - Zip Code:99301-7017
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4403 W COURT ST
Practice Address - Street 2:STE J
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-2879
Practice Address - Country:US
Practice Address - Phone:509-547-9695
Practice Address - Fax:509-547-5017
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-28
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD60376271152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2034845Medicaid