Provider Demographics
NPI:1063646511
Name:GORDON, KIMBERLY (PT)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7197
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55903-7197
Mailing Address - Country:US
Mailing Address - Phone:507-322-3460
Mailing Address - Fax:507-322-3450
Practice Address - Street 1:3100 19TH ST NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901
Practice Address - Country:US
Practice Address - Phone:507-322-3460
Practice Address - Fax:507-322-3450
Is Sole Proprietor?:No
Enumeration Date:2009-05-13
Last Update Date:2013-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN76542251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic