Provider Demographics
NPI:1730103359
Name:GANTZ, ROBERT W (ARPN)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:GANTZ
Suffix:
Gender:M
Credentials:ARPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1802 YAKIMA AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-5304
Mailing Address - Country:US
Mailing Address - Phone:253-382-8540
Mailing Address - Fax:253-382-8545
Practice Address - Street 1:1802 YAKIMA AVE STE 204
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-5304
Practice Address - Country:US
Practice Address - Phone:253-382-8540
Practice Address - Fax:253-382-8545
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP60292404363L00000X, 363LA2200X
NE110790363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2020584Medicaid
KS200632670AMedicaid
NE38767OtherBCBS
280280Medicare PIN