Healthcare Provider Details

I. General information

NPI: 1932292695
Provider Name (Legal Business Name): IRA KANTROWITZ-GORDON CNM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 08/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 MARTIN L KING JR WAY
TACOMA WA
98405-4234
US

IV. Provider business mailing address

315 MARTIN L KING JR WAY
TACOMA WA
98405-4234
US

V. Phone/Fax

Practice location:
  • Phone: 253-459-8231
  • Fax: 253-459-7863
Mailing address:
  • Phone: 253-459-8231
  • Fax: 253-459-7863

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License NumberAP30005021
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberAP30005021
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberAP30005021
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: