Basic Information
| Provider Information | |||||||||
| NPI: | 1417319922 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DULETZKE | ||||||||
| FirstName: | NICHOLAS | ||||||||
| MiddleName: | TAYLOR | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 N 1900 E | ||||||||
| Address2: | |||||||||
| City: | SALT LAKE CITY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841320002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015816803 | ||||||||
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| Practice Location | |||||||||
| Address1: | 505 NE 87TH AVE STE 301 | ||||||||
| Address2: | |||||||||
| City: | VANCOUVER | ||||||||
| State: | WA | ||||||||
| PostalCode: | 986641965 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3605141854 | ||||||||
| FaxNumber: | 3605146063 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2016 | ||||||||
| LastUpdateDate: | 06/08/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD61281239 | WA | N | Allopathic & Osteopathic Physicians | Surgery | 2086S0102X | MD61281239 | WA | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2086S0127X | MD61281239 | WA | Y | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery |
No ID Information.