Provider Demographics
NPI:1740688092
Name:GAWEDA, IAN
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:GAWEDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 112TH ST SE STE C
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98208-5283
Mailing Address - Country:US
Mailing Address - Phone:425-355-5000
Mailing Address - Fax:
Practice Address - Street 1:711 112TH ST SE STE C
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98208-5283
Practice Address - Country:US
Practice Address - Phone:425-355-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-17
Last Update Date:2014-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60487433225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist