Healthcare Provider Details

I. General information

NPI: 1356334460
Provider Name (Legal Business Name): GORDON S NISHIMOTO DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 03/31/2025
Certification Date: 03/31/2025
Deactivation Date: 03/27/2006
Reactivation Date: 09/18/2006

III. Provider practice location address

10821 19TH AVE SE STE 201
EVERETT WA
98208-5103
US

IV. Provider business mailing address

1100 PACIFIC AVE STE 300
EVERETT WA
98201-4261
US

V. Phone/Fax

Practice location:
  • Phone: 425-337-7000
  • Fax: 425-338-2408
Mailing address:
  • Phone: 425-337-7000
  • Fax: 425-338-2488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberPO00000725
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: