Basic Information
| Provider Information | |||||||||
| NPI: | 1912906314 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICHOLAS | ||||||||
| FirstName: | EVA | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2709 HEMLOCK ST. | ||||||||
| Address2: | |||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603732547 | ||||||||
| FaxNumber: | 3604798268 | ||||||||
| Practice Location | |||||||||
| Address1: | 2709 HEMLOCK ST. | ||||||||
| Address2: | |||||||||
| City: | BREMERTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3603732547 | ||||||||
| FaxNumber: | 3604798268 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2005 | ||||||||
| LastUpdateDate: | 06/22/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | 38314 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RC0000X | MD60063789 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 64067218 | 05 | KY | MEDICAID |