Provider Demographics
NPI: | 1710062492 |
---|---|
Name: | VEDDER, NICHOLAS B (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | NICHOLAS |
Middle Name: | B |
Last Name: | VEDDER |
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: | PO BOX 50095 |
Mailing Address - Street 2: | |
Mailing Address - City: | SEATTLE |
Mailing Address - State: | WA |
Mailing Address - Zip Code: | 98145-5095 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 206-520-5700 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 325 9TH AVE |
Practice Address - Street 2: | |
Practice Address - City: | SEATTLE |
Practice Address - State: | WA |
Practice Address - Zip Code: | 98104-2420 |
Practice Address - Country: | US |
Practice Address - Phone: | 206-520-5000 |
Practice Address - Fax: | 206-744-8948 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-10-25 |
Last Update Date: | 2023-01-23 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
WA | MD00020104 | 2082S0105X, 2086S0122X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2086S0122X | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery |
No | 2082S0105X | Allopathic & Osteopathic Physicians | Plastic Surgery | Surgery of the Hand |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
WA | 1710062492 | Medicaid | |
WA | 0232124 | Other | L&I |
WA | 1710062492 | Medicaid | |
WA | 0232124 | Other | L&I |