Provider Demographics
NPI:1760564959
Name:THEMELIS, NICHOLAS JAMES (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:JAMES
Last Name:THEMELIS
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 1:11601 PACIFIC AVE S
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98444-5435
Mailing Address - Country:US
Mailing Address - Phone:253-536-3336
Mailing Address - Fax:253-536-3242
Practice Address - Street 1:11601 PACIFIC AVE S
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98444-5435
Practice Address - Country:US
Practice Address - Phone:253-536-3336
Practice Address - Fax:253-536-3242
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00025303208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1018430Medicaid
WATH0534OtherREGENCE BLUESHIELD
WA1018430Medicaid