Provider Demographics
NPI:1063960615
Name:DEMKO, ROBERT WAYNE (CN)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:WAYNE
Last Name:DEMKO
Suffix:
Gender:M
Credentials:CN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2522 N PROCTOR ST # 425
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98406-5338
Mailing Address - Country:US
Mailing Address - Phone:844-705-0990
Mailing Address - Fax:253-444-0514
Practice Address - Street 1:2522 N PROCTOR ST # 425
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98406-5338
Practice Address - Country:US
Practice Address - Phone:844-705-0990
Practice Address - Fax:253-444-0514
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-13
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACN 60687076133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist