Provider Demographics
NPI:1982740825
Name:CORNU-LABAT, GASTON (MD)
Entity Type:Individual
Prefix:
First Name:GASTON
Middle Name:
Last Name:CORNU-LABAT
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 1:908 10TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:WA
Mailing Address - Zip Code:98848-1376
Mailing Address - Country:US
Mailing Address - Phone:509-787-5368
Mailing Address - Fax:509-787-2016
Practice Address - Street 1:908 10TH AVE SW
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:WA
Practice Address - Zip Code:98848-1376
Practice Address - Country:US
Practice Address - Phone:509-787-5368
Practice Address - Fax:509-787-2016
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00040392208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
276146Medicare ID - Type Unspecified
H18664Medicare UPIN