Provider Demographics
NPI:1841239720
Name:NICACIO, ROBERT A (OD)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:A
Last Name:NICACIO
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 1:912 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-3136
Mailing Address - Country:US
Mailing Address - Phone:360-694-6541
Mailing Address - Fax:360-696-2578
Practice Address - Street 1:225 NE 4TH AVE
Practice Address - Street 2:
Practice Address - City:CAMAS
Practice Address - State:WA
Practice Address - Zip Code:98607-2125
Practice Address - Country:US
Practice Address - Phone:360-834-2063
Practice Address - Fax:360-834-5375
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001808TX152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2023141Medicaid
WAAB13044Medicare ID - Type Unspecified
U29339Medicare UPIN
WA4148630001Medicare NSC