Individual
GEOFFREY OWEN MCNICOLL
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
15214 CANYON RD E, STE 100, PUYALLUP, WA 98375-7472
(253) 539-4200
(253) 539-6005
Mailing address
15214 CANYON RD E, STE 100, PUYALLUP, WA 98375-7472
(253) 539-4200
(253) 539-6005
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
MD60180279
WA
390200000X
Student in an Organized Health Care Education/Training Program
EC081117
ME
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0273458
STATE L&I
WA
01
—
0273460
STATE L&I
WA
Enumeration date
09/20/2006
Last updated
03/31/2011
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