Provider Demographics
NPI:1366410375
Name:NICOLOV, LAURENT
Entity type:Individual
Prefix:
First Name:LAURENT
Middle Name:
Last Name:NICOLOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 PACIFIC AVE STE 500
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4189
Practice Address - Country:US
Practice Address - Phone:425-339-5400
Practice Address - Fax:425-339-5454
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2012-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA37016207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAMD00037016OtherLICENSE
WA1008606Medicaid
WA1008606Medicaid