Provider Demographics
NPI:1003210709
Name:GAMGONEISHVILI, YEFIM (LAC)
Entity Type:Individual
Prefix:
First Name:YEFIM
Middle Name:
Last Name:GAMGONEISHVILI
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 W SREET
Mailing Address - Street 2:
Mailing Address - City:PORT TOWNSEND
Mailing Address - State:WA
Mailing Address - Zip Code:98368
Mailing Address - Country:US
Mailing Address - Phone:360-379-6655
Mailing Address - Fax:
Practice Address - Street 1:2033 E SIMS WAY
Practice Address - Street 2:
Practice Address - City:PORT TOWNSEND
Practice Address - State:WA
Practice Address - Zip Code:98368-6905
Practice Address - Country:US
Practice Address - Phone:360-344-2957
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-09
Last Update Date:2014-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAC60461823171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist