Provider Demographics
NPI:1265452833
Name:GORDON, RANDY M (ARNP)
Entity Type:Individual
Prefix:MR
First Name:RANDY
Middle Name:M
Last Name:GORDON
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7547 JACQUE RD
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:FL
Mailing Address - Zip Code:34667-7163
Mailing Address - Country:US
Mailing Address - Phone:727-862-8561
Mailing Address - Fax:727-861-1951
Practice Address - Street 1:7547 JACQUE RD
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:FL
Practice Address - Zip Code:34667-7163
Practice Address - Country:US
Practice Address - Phone:727-862-8561
Practice Address - Fax:727-861-1951
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL3203702363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q25454Medicare UPIN
U34717ZMedicare ID - Type Unspecified