Provider Demographics
NPI:1053358861
Name:MEDESKI-NICACIO, LINDA R (OD)
Entity type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:R
Last Name:MEDESKI-NICACIO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:912 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98660-3136
Mailing Address - Country:US
Mailing Address - Phone:360-694-6541
Mailing Address - Fax:360-696-2578
Practice Address - Street 1:912 MAIN ST
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98660-3136
Practice Address - Country:US
Practice Address - Phone:360-694-6541
Practice Address - Fax:360-696-2578
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00001999152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2023133Medicaid
WA4148630002Medicare NSC
WA2023133Medicaid
U44972Medicare UPIN