Provider Demographics
NPI:1801283262
Name:CHURCH, NICHOLAS TYLER
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:TYLER
Last Name:CHURCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15809 BEAR CREEK PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-1542
Mailing Address - Country:US
Mailing Address - Phone:425-882-6100
Mailing Address - Fax:
Practice Address - Street 1:15809 BEAR CREEK PKWY STE 100
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-1542
Practice Address - Country:US
Practice Address - Phone:425-882-6100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-22
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP60850304207Q00000X
PAOT016657207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine