Organization
MV-ANESTHESIA PS
Active
Organization subpart
No
Provider details
NPI number
Authorized official
TERRILYNN NICKLIN (BILLING MANAGER)
(360) 434-3009
Entity
Organization
Contact information
Practice address
110 N 30TH ST, MOUNT VERNON, WA 98273-3668
(360) 434-3009
(360) 895-5380
Mailing address
PO BOX 11810, BAINBRIDGE ISLAND, WA 98110-5810
(360) 434-3009
(360) 895-5380
Taxonomy
Speciality
Code
Description
License number
State
207L00000X
Anesthesiology Physician
Primary
MD00033163
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0196474
L&I
WA
01
—
1577DO
REGENCE
WA
Enumeration date
02/25/2007
Last updated
06/26/2008
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