Provider Demographics
NPI:1285070003
Name:GWIN, GERALD GRANT JR (LMP)
Entity type:Individual
Prefix:MR
First Name:GERALD
Middle Name:GRANT
Last Name:GWIN
Suffix:JR
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5448 NW WESTGATE RD
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-6834
Mailing Address - Country:US
Mailing Address - Phone:360-229-9882
Mailing Address - Fax:
Practice Address - Street 1:10513 SILVERDALE WAY NW
Practice Address - Street 2:SUITE 101
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-9499
Practice Address - Country:US
Practice Address - Phone:360-698-4411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-20
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60308827225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist