Provider Demographics
NPI:1376569566
Name:DEYSINE, GASTON R (MD)
Entity Type:Individual
Prefix:
First Name:GASTON
Middle Name:R
Last Name:DEYSINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 OLIVE WAY MSC M4-PA
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98101-1873
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:33501 1ST WAY S
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-6208
Practice Address - Country:US
Practice Address - Phone:253-838-2400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00030831207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAUS4311896OtherAETNA/USHC SPECIALIST
WA1119DEOtherBLUE SHIELD
WA8268732Medicaid
WAMD4555WOtherALASKA MEDICAID
WA0039594OtherLABOR & INDUSTRY
WAAB19940Medicare PIN
WAMD4555WOtherALASKA MEDICAID