Provider Demographics
NPI:1336256692
Name:NIKOM WANNARACHUE, M.D., INC. P.S.
Entity Type:Organization
Organization Name:NIKOM WANNARACHUE, M.D., INC. P.S.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:DR
Authorized Official - First Name:NIKOM
Authorized Official - Middle Name:
Authorized Official - Last Name:WANNARACHUE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-586-1157
Mailing Address - Street 1:721 S AUBURN ST
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-5665
Mailing Address - Country:US
Mailing Address - Phone:509-586-1157
Mailing Address - Fax:509-582-4189
Practice Address - Street 1:721 S AUBURN ST
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-5665
Practice Address - Country:US
Practice Address - Phone:509-586-1157
Practice Address - Fax:509-582-4189
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-24
Last Update Date:2011-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7108723Medicaid
WA7108723Medicaid