Provider Demographics
NPI:1548670409
Name:NEWKIRK, GIDEON
Entity type:Individual
Prefix:
First Name:GIDEON
Middle Name:
Last Name:NEWKIRK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:GIDEON
Other - Middle Name:PAUL
Other - Last Name:NEWKIRK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMP
Mailing Address - Street 1:2015 DELANO RD
Mailing Address - Street 2:
Mailing Address - City:CENTRALIA
Mailing Address - State:WA
Mailing Address - Zip Code:98531-2044
Mailing Address - Country:US
Mailing Address - Phone:360-807-1026
Mailing Address - Fax:
Practice Address - Street 1:802 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-2849
Practice Address - Country:US
Practice Address - Phone:360-736-6263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-01
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60414378225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist