Healthcare Provider Details

I. General information

NPI: 1063808517
Provider Name (Legal Business Name): WOJCIECH GRYC M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2015
Last Update Date: 08/26/2021
Certification Date: 08/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S 43RD ST
RENTON WA
98055-5714
US

IV. Provider business mailing address

3600 LIND AVE SW SUITE 100 ATTN CREDENTIALING
RENTON WA
98057-4970
US

V. Phone/Fax

Practice location:
  • Phone: 425-690-3585
  • Fax: 425-690-9585
Mailing address:
  • Phone: 425-690-2715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberMD60775259
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: