Provider Demographics
NPI:1659100485
Name:WATABAYASHI, GAVIN E (DPT)
Entity type:Individual
Prefix:
First Name:GAVIN
Middle Name:E
Last Name:WATABAYASHI
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1845 VILLAGE CENTER CIR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89134-6369
Mailing Address - Country:US
Mailing Address - Phone:702-723-9006
Mailing Address - Fax:702-664-0466
Practice Address - Street 1:1845 VILLAGE CENTER CIR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89134-6369
Practice Address - Country:US
Practice Address - Phone:702-723-9006
Practice Address - Fax:702-664-0466
Is Sole Proprietor?:No
Enumeration Date:2024-07-30
Last Update Date:2024-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6485225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant