Provider Demographics
NPI:1790173185
Name:VAN WYK, PAUL
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:VAN WYK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1712
Mailing Address - Street 2:
Mailing Address - City:ZILLAH
Mailing Address - State:WA
Mailing Address - Zip Code:98953-1712
Mailing Address - Country:US
Mailing Address - Phone:509-952-9838
Mailing Address - Fax:
Practice Address - Street 1:402 S 4TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3546
Practice Address - Country:US
Practice Address - Phone:509-952-9838
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-07
Last Update Date:2016-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG60516729171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator