Provider Demographics
NPI:1790550333
Name:GAUCK, BRYAN KEITH (LPN)
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:KEITH
Last Name:GAUCK
Suffix:
Gender:M
Credentials:LPN
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 1035
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRINGS
Mailing Address - State:NV
Mailing Address - Zip Code:89429-1035
Mailing Address - Country:US
Mailing Address - Phone:859-414-5917
Mailing Address - Fax:
Practice Address - Street 1:4200 6TH AVE SE STE 201
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1042
Practice Address - Country:US
Practice Address - Phone:360-459-8311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-22
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2029637164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse