Provider Demographics
NPI:1427183144
Name:MYCO, GORDON A (DC)
Entity Type:Individual
Prefix:DR
First Name:GORDON
Middle Name:A
Last Name:MYCO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:919 STATE AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-4284
Mailing Address - Country:US
Mailing Address - Phone:360-653-6010
Mailing Address - Fax:360-653-6008
Practice Address - Street 1:919 STATE AVE STE 102
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-4284
Practice Address - Country:US
Practice Address - Phone:360-653-6010
Practice Address - Fax:360-653-6008
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2012-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3460111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8879358OtherMEDICARE PTAN #