Provider Demographics
NPI:1386001840
Name:GORGONIO, MIKA (LMT)
Entity Type:Individual
Prefix:
First Name:MIKA
Middle Name:
Last Name:GORGONIO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91-1026 KAIMALIE ST APT Q1
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-5012
Mailing Address - Country:US
Mailing Address - Phone:808-366-0215
Mailing Address - Fax:
Practice Address - Street 1:91-1026 KAIMALIE ST APT Q1
Practice Address - Street 2:
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-5012
Practice Address - Country:US
Practice Address - Phone:808-366-0215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-28
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIMAT 13853174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist