Healthcare Provider Details

I. General information

NPI: 1417319922
Provider Name (Legal Business Name): NICHOLAS TAYLOR DULETZKE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2016
Last Update Date: 06/08/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 NE 87TH AVE STE 301
VANCOUVER WA
98664-1965
US

IV. Provider business mailing address

30 N 1900 E
SALT LAKE CITY UT
84132-0002
US

V. Phone/Fax

Practice location:
  • Phone: 360-514-1854
  • Fax: 360-514-6063
Mailing address:
  • Phone: 801-581-6803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD61281239
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberMD61281239
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberMD61281239
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: