Healthcare Provider Details

I. General information

NPI: 1639172927
Provider Name (Legal Business Name): JONATHAN C GAMSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 02/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2116 EAST SECTION STREET
MOUNT VERNON WA
98274-9124
US

IV. Provider business mailing address

2116 EAST SECTION STREET
MOUNT VERNON WA
98274-9124
US

V. Phone/Fax

Practice location:
  • Phone: 360-428-1700
  • Fax: 360-848-4350
Mailing address:
  • Phone: 360-428-1700
  • Fax: 360-848-4350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD00036055
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: