Basic Information
| Provider Information | |||||||||
| NPI: | 1699711788 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICHOLS | ||||||||
| FirstName: | ALLAN | ||||||||
| MiddleName: | ROMINE | ||||||||
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| Credential: | P.T. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10452 SILVERDALE WAY NW | ||||||||
| Address2: | |||||||||
| City: | SILVERDALE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983839411 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603077500 | ||||||||
| FaxNumber: | 3603077530 | ||||||||
| Practice Location | |||||||||
| Address1: | 9621 RIDGETOP BLVD NW | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | SILVERDALE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 983838502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3607823300 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 03/26/2018 | ||||||||
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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 | 225100000X | PT00008362 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 8424244 | 05 | WA | MEDICAID | 195813 | 01 | WA | LABOR & INDUSTRIES | OTHER | 7166701 | 01 | AETNA | OTHER | 8918NI | 01 | REGENCE BLUESHIELD | OTHER |