Provider Demographics
NPI:1922799352
Name:SHAHAM, NIKOLE KORAL (DO)
Entity Type:Individual
Prefix:
First Name:NIKOLE
Middle Name:KORAL
Last Name:SHAHAM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 N 41ST ST APT K
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98901-1237
Mailing Address - Country:US
Mailing Address - Phone:805-208-0086
Mailing Address - Fax:
Practice Address - Street 1:BUTLER-HANEY HALL, 200 UNIVERSITY PKWY
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98901
Practice Address - Country:US
Practice Address - Phone:509-452-5900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-17
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program