Provider Demographics
NPI:1063021962
Name:GORDON, MATTHEW
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 GARDEN LANE
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:WV
Mailing Address - Zip Code:26184
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:31 GARDEN LANE
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:WV
Practice Address - Zip Code:26184
Practice Address - Country:US
Practice Address - Phone:304-266-1237
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant