Provider Demographics
NPI:1245613694
Name:MIYAKAWA, JOHN (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MIYAKAWA
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12337 ASHLEY DR
Mailing Address - Street 2:SUITE F
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-2753
Mailing Address - Country:US
Mailing Address - Phone:228-365-6932
Mailing Address - Fax:
Practice Address - Street 1:12337 ASHLEY DR
Practice Address - Street 2:SUITE F
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2753
Practice Address - Country:US
Practice Address - Phone:228-365-6932
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-02
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical