Provider Demographics
NPI:1831150754
Name:GUNN, JACK MATTHEW (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:MATTHEW
Last Name:GUNN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:732 SUMMITVIEW AVE
Mailing Address - Street 2:#633
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-3032
Mailing Address - Country:US
Mailing Address - Phone:509-573-3448
Mailing Address - Fax:509-574-4481
Practice Address - Street 1:110 S 9TH AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-3315
Practice Address - Country:US
Practice Address - Phone:509-574-4440
Practice Address - Fax:509-574-4481
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00039736207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8313694Medicaid
E02892Medicare UPIN
G8861586Medicare PIN