Basic Information
| Provider Information | |||||||||
| NPI: | 1093897167 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IWASAKI | ||||||||
| FirstName: | MAKOTO | ||||||||
| MiddleName: | BRANDON | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 E NELSON AVE | ||||||||
| Address2: | |||||||||
| City: | ALEXANDRIA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 223012035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9519905318 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6355 WALKER LN | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | ALEXANDRIA | ||||||||
| State: | VA | ||||||||
| PostalCode: | 223103245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7039212167 | ||||||||
| FaxNumber: | 7039211789 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | 2305204802 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No ID Information.