Healthcare Provider Details

I. General information

NPI: 1356577621
Provider Name (Legal Business Name): JONATHAN LEE GAGE LMP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/01/2009
Last Update Date: 06/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

739 S MISSION ST
WENATCHEE WA
98801-3079
US

IV. Provider business mailing address

739 S MISSION ST
WENATCHEE WA
98801-3079
US

V. Phone/Fax

Practice location:
  • Phone: 509-884-4357
  • Fax:
Mailing address:
  • Phone: 509-884-4357
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License NumberNA60043977
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code172M00000X
TaxonomyMechanotherapist
License NumberMA60041531
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: