Basic Information
| Provider Information | |||||||||
| NPI: | 1255438586 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCNICOLL | ||||||||
| FirstName: | GEOFFREY | ||||||||
| MiddleName: | OWEN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15214 CANYON RD E | ||||||||
| Address2: | STE 100 | ||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983757472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535394200 | ||||||||
| FaxNumber: | 2535396005 | ||||||||
| Practice Location | |||||||||
| Address1: | 15214 CANYON RD E | ||||||||
| Address2: | STE 100 | ||||||||
| City: | PUYALLUP | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983757472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535394200 | ||||||||
| FaxNumber: | 2535396005 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 03/31/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | EC081117 | ME | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | MD60180279 | WA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0273458 | 01 | WA | STATE L&I | OTHER | 0273460 | 01 | WA | STATE L&I | OTHER |