Provider Demographics
NPI:1790009132
Name:NISHINAGA, MEGHAN GOULD (MD)
Entity Type:Individual
Prefix:
First Name:MEGHAN
Middle Name:GOULD
Last Name:NISHINAGA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MEGHAN
Other - Middle Name:DETRICH
Other - Last Name:GOULD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
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:206-320-4194
Practice Address - Street 1:800 5TH AVE STE 600
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-3186
Practice Address - Country:US
Practice Address - Phone:206-533-2944
Practice Address - Fax:206-233-7489
Is Sole Proprietor?:No
Enumeration Date:2010-03-14
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61095016208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
RES000Medicare UPIN