Provider Demographics
NPI:1306929328
Name:DEACON, GARY (PT)
Entity type:Individual
Prefix:MR
First Name:GARY
Middle Name:
Last Name:DEACON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:181 FAIRVIEW LN
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-4809
Mailing Address - Country:US
Mailing Address - Phone:209-532-6463
Mailing Address - Fax:209-532-3420
Practice Address - Street 1:181 FAIRVIEW LN
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-4809
Practice Address - Country:US
Practice Address - Phone:209-532-6463
Practice Address - Fax:209-532-3420
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 11939225100000X
CA332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ20662ZMedicare PIN
CA4619230001Medicare PIN
CA0PT119391Medicare PIN