Provider Demographics
NPI:1619149929
Name:IWASAKI, GORDON (PA)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:
Last Name:IWASAKI
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6221 METROPOLITAN ST
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92009-3096
Mailing Address - Country:US
Mailing Address - Phone:760-753-7127
Mailing Address - Fax:760-334-0399
Practice Address - Street 1:40960 CALIFORNIA OAKS RD
Practice Address - Street 2:#225
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-5747
Practice Address - Country:US
Practice Address - Phone:951-600-8858
Practice Address - Fax:951-672-7798
Is Sole Proprietor?:No
Enumeration Date:2008-03-26
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
13726363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical