Healthcare Provider Details

I. General information

NPI: 1619438744
Provider Name (Legal Business Name): BRYANT MOTYKOWSKI FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2019
Last Update Date: 05/13/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 NE 87TH AVE STE 320
VANCOUVER WA
98664-1965
US

IV. Provider business mailing address

2160 S 1ST AVE
MAYWOOD IL
60153-3328
US

V. Phone/Fax

Practice location:
  • Phone: 360-514-2550
  • Fax: 360-514-1927
Mailing address:
  • Phone: 708-216-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP61018849
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.018590
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: