Provider Demographics
NPI:1073394920
Name:SIU, GORDON (RN)
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:
Last Name:SIU
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5011 RUSSELL ST APT 4
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:MI
Mailing Address - Zip Code:48640-2873
Mailing Address - Country:US
Mailing Address - Phone:989-980-4673
Mailing Address - Fax:
Practice Address - Street 1:4000 WELLNESS DR
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:MI
Practice Address - Zip Code:48670-2000
Practice Address - Country:US
Practice Address - Phone:989-839-1550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-06
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1601344146L00000X
MI4704253423163WN0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WN0800XNursing Service ProvidersRegistered NurseNeuroscience
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic