Provider Demographics
NPI:1356334460
Name:NISHIMOTO, GORDON S (DPM)
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:S
Last Name:NISHIMOTO
Suffix:
Gender:
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 PACIFIC AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98201-4261
Mailing Address - Country:US
Mailing Address - Phone:425-337-7000
Mailing Address - Fax:425-338-2488
Practice Address - Street 1:10821 19TH AVE SE STE 201
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-5103
Practice Address - Country:US
Practice Address - Phone:425-337-7000
Practice Address - Fax:425-338-2408
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2025-03-31
Deactivation Date:2006-03-27
Deactivation Code:
Reactivation Date:2006-09-18
Provider Licenses
StateLicense IDTaxonomies
WAPO00000725213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1036258Medicaid
WAAB29342Medicare ID - Type Unspecified
WA8484396Medicaid