MEDICARE: MR. GORDON N IWAHASHI NCMMT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist

General Provider Information

NPI Number	:	1316163009
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. GORDON N IWAHASHI NCMMT

Provider Business Mailing Address
First Line	:	5707 N PALM AVE
Second Line	:	#101
City	:	FRESNO
State	:	CA
Zip	:	93704-1843
Country	:	US
Telephone Number	:	559-432-4339
Fax Number	:	559-432-4328

Provider Business Practice Location Address
First Line	:	5707 N PALM AVE
Second Line	:	#101
City	:	FRESNO
State	:	CA
Zip	:	93704-1843
Country	:	US
Telephone Number	:	559-432-4339
Fax Number	:	559-432-4328

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/18/2007
Last Update Date	:	07/08/2007

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