Provider Demographics
NPI:1114055365
Name:GORDON, BOSHA A (APRN)
Entity Type:Individual
Prefix:MS
First Name:BOSHA
Middle Name:A
Last Name:GORDON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2829 INDIANA ST NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-3427
Mailing Address - Country:US
Mailing Address - Phone:505-508-1304
Mailing Address - Fax:
Practice Address - Street 1:1001 MEDICAL ARTS AVE NE # UNM
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-2708
Practice Address - Country:US
Practice Address - Phone:505-272-5132
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2011-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP00393363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily