Provider Demographics
NPI:1912906314
Name:NICHOLAS, EVA M (MD)
Entity Type:Individual
Prefix:MRS
First Name:EVA
Middle Name:M
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2709 HEMLOCK ST.
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98310
Mailing Address - Country:US
Mailing Address - Phone:360-373-2547
Mailing Address - Fax:360-479-8268
Practice Address - Street 1:2709 HEMLOCK ST.
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310
Practice Address - Country:US
Practice Address - Phone:360-373-2547
Practice Address - Fax:360-479-8268
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2021-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38314207RC0000X
WAMD60063789207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64067218Medicaid
KY64067218Medicaid
KYH86955Medicare UPIN
1262111Medicare ID - Type Unspecified