1114177169 NPI number — MR. GARY CLAYTON ISHAM CDP

Table of content: KAITLYN ROSE KELLER (NPI 1588535959)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114177169 NPI number — MR. GARY CLAYTON ISHAM CDP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ISHAM
Provider First Name:
GARY
Provider Middle Name:
CLAYTON
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CDP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114177169
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/20/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17500 S SKYRIDGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNT VERNON
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98274-7768
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
425-501-6257
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17337 RESERVATION RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA CONNER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98257-8802
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-466-1024
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/26/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  CP00005949 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 199286 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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