Provider Demographics
NPI:1932292695
Name:KANTROWITZ-GORDON, IRA (CNM)
Entity type:Individual
Prefix:
First Name:IRA
Middle Name:
Last Name:KANTROWITZ-GORDON
Suffix:
Gender:M
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:315 MARTIN L KING JR WAY
Mailing Address - Street 2:
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-4234
Mailing Address - Country:US
Mailing Address - Phone:253-459-8231
Mailing Address - Fax:253-459-7863
Practice Address - Street 1:315 MARTIN L KING JR WAY
Practice Address - Street 2:
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-4234
Practice Address - Country:US
Practice Address - Phone:253-459-8231
Practice Address - Fax:253-459-7863
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2016-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30005021176B00000X, 367A00000X, 363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9624545Medicaid
WAP19767Medicare UPIN
WAG8878220Medicare PIN
WAG8878220Medicare PIN