Provider Demographics
NPI:1124571823
Name:VANWYNGARDEN, BRIAN PAUL ROYAL (LMT)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:PAUL ROYAL
Last Name:VANWYNGARDEN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:435 21ST ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-8848
Mailing Address - Country:US
Mailing Address - Phone:612-638-8449
Mailing Address - Fax:
Practice Address - Street 1:2416 13TH ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-2546
Practice Address - Country:US
Practice Address - Phone:503-798-2918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-28
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR21790171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor