Provider Demographics
NPI:1447344528
Name:VRACIN, WYLIE NICHOLAS (MD)
Entity type:Individual
Prefix:
First Name:WYLIE
Middle Name:NICHOLAS
Last Name:VRACIN
Suffix:
Gender:M
Credentials:MD
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 1440
Mailing Address - Street 2:
Mailing Address - City:COUPEVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98239-1440
Mailing Address - Country:US
Mailing Address - Phone:360-678-6576
Mailing Address - Fax:360-678-3970
Practice Address - Street 1:202 NORTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:COUPEVILLE
Practice Address - State:WA
Practice Address - Zip Code:98239
Practice Address - Country:US
Practice Address - Phone:360-678-6576
Practice Address - Fax:360-678-3970
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00020146207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1905504Medicaid
A09030Medicare UPIN
WA1905504Medicaid