Provider Demographics
NPI:1073606273
Name:GORDON, RICK (CRNA)
Entity Type:Individual
Prefix:
First Name:RICK
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1419 CHATTANOOGA AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:DALTON
Mailing Address - State:GA
Mailing Address - Zip Code:30720-2642
Mailing Address - Country:US
Mailing Address - Phone:706-259-4435
Mailing Address - Fax:706-226-2283
Practice Address - Street 1:1200 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:DALTON
Practice Address - State:GA
Practice Address - Zip Code:30720-2529
Practice Address - Country:US
Practice Address - Phone:706-259-4435
Practice Address - Fax:706-226-2283
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN04307163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000487352CMedicaid
GA43ZCBFJ10Medicare ID - Type Unspecified