Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208800000X | Urologist | MD61148901 | WA |
NPI | 1053707398 |
---|---|
Provider Name | Tristan Marriner Nicholson |
First Address | Seattle, WA 98145-5095 |
Second Address | Seattle, WA 98195-0001 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 14/04/2015 |
Last Update Date | 03/05/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1053707398 | (05) | WA |