Provider Demographics
NPI:1184990590
Name:VAN NIELEN, DOMINIC LEE (MD)
Entity type:Individual
Prefix:
First Name:DOMINIC
Middle Name:LEE
Last Name:VAN NIELEN
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 1:1100 PACIFIC AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-4261
Mailing Address - Country:US
Mailing Address - Phone:425-339-2433
Mailing Address - Fax:425-339-8273
Practice Address - Street 1:19200 N KELSEY ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1431
Practice Address - Country:US
Practice Address - Phone:425-339-2433
Practice Address - Fax:425-339-8237
Is Sole Proprietor?:No
Enumeration Date:2012-03-29
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD94626207X00000X
WAMD61002589207XS0114X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2249981Medicaid
WA466835OtherWA L&I