Provider Demographics
NPI:1265094700
Name:CHANG, NICHOLAS (DPM)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:
Last Name:CHANG
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:DR
Other - First Name:NICHOLAS
Other - Middle Name:HANG-LUEN
Other - Last Name:CHANG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPM
Mailing Address - Street 1:1617 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-4503
Mailing Address - Country:US
Mailing Address - Phone:360-424-7018
Mailing Address - Fax:
Practice Address - Street 1:1617 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-4503
Practice Address - Country:US
Practice Address - Phone:360-424-7018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-04
Last Update Date:2023-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO61087244213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery