Doctor Name: | MR. BRIAN BENNETT KOLDYKE |
NPI Number: | 1609203363 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | MSN, FNP-C |
License Number: | 5850890-4405 |
Business Practice Address: | 51600 Huntington Rd La Pine, OR - 977398887 |
Business Phone Number: | 5415363435 |
Business Fax Number: | 5415368047 |
Mailing Address: | Po Box 3300, LA PINE |
State: | OR |
Postal Code: | 977393300 |
Phone Number: | 5415363435 |
Fax Number: | 5415368047 |
NPI Enumeration Date: | 09/26/2013 |
NPI Last Update Date: | 12/10/2013 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 363LF0000X |
License Number: | 5850890-4405 |
Healthcare Provider Taxonomy: (Secondary) | N |
State: | UT |
Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
Taxonomy Classification: | Nurse Practitioner |
Taxonomy Specialization: | Family |
Taxonomy Definition: |