Healthcare Provider Details

I. General information

NPI: 1669024030
Provider Name (Legal Business Name): ISSAC AMBROSE KONKLER LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2019
Last Update Date: 10/09/2025
Certification Date: 10/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11015 NE FOURTH PLAIN BLVD STE B
VANCOUVER WA
98662
US

IV. Provider business mailing address

11015 NE FOURTH PLAIN BLVD STE B
VANCOUVER WA
98662-6314
US

V. Phone/Fax

Practice location:
  • Phone: 360-892-0451
  • Fax: 360-892-1601
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMA60970420
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: