Healthcare Provider Details

I. General information

NPI: 1730286493
Provider Name (Legal Business Name): MR. MICAH GWINN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1660 S COLUMBIAN WAY RAD-ONC (174)
SEATTLE WA
98108-1532
US

IV. Provider business mailing address

1660 S COLUMBIAN WAY RAD-ONC (174)
SEATTLE WA
98108-1532
US

V. Phone/Fax

Practice location:
  • Phone: 206-768-5356
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471R0002X
TaxonomyRadiation Therapy Radiologic Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: