Provider Demographics
NPI:1033461116
Name:GORDON, LEAH M (NP-C)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:M
Last Name:GORDON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44 MAYNARD ST
Mailing Address - Street 2:APARTMENT 1
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-4620
Mailing Address - Country:US
Mailing Address - Phone:617-504-9627
Mailing Address - Fax:
Practice Address - Street 1:100 BLOSSOM ST MASSACHUSETTS GENERAL HOSPITAL
Practice Address - Street 2:DEPT OF RADIATION ONCOLOGY, COX 3
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114
Practice Address - Country:US
Practice Address - Phone:617-726-5184
Practice Address - Fax:617-983-7860
Is Sole Proprietor?:No
Enumeration Date:2012-10-12
Last Update Date:2014-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN258765363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily