Provider Demographics
NPI:1336351147
Name:PROCACCINI, NICHOLAS J (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:J
Last Name:PROCACCINI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:1221 MADISON ST STE 1220
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-1356
Practice Address - Country:US
Practice Address - Phone:206-215-4250
Practice Address - Fax:206-215-4252
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD60078001207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8898250Medicare PIN