Provider Demographics
NPI:1669024030
Name:KONKLER, ISSAC AMBROSE (LMT)
Entity type:Individual
Prefix:MR
First Name:ISSAC
Middle Name:AMBROSE
Last Name:KONKLER
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11015 NE FOURTH PLAIN BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98662-6314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11015 NE FOURTH PLAIN BLVD
Practice Address - Street 2:STE B
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662
Practice Address - Country:US
Practice Address - Phone:360-892-0451
Practice Address - Fax:360-892-1601
Is Sole Proprietor?:No
Enumeration Date:2019-07-15
Last Update Date:2025-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60970420225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist