Provider Demographics
NPI:1750844908
Name:QUAM, NICHOLAS RUSSELL (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:RUSSELL
Last Name:QUAM
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 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:1101 MADISON ST STE 1500
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-3551
Practice Address - Country:US
Practice Address - Phone:206-991-2000
Practice Address - Fax:206-991-2005
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-12
Last Update Date:2023-09-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD61411043207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2254766Medicaid