Provider Demographics
NPI:1265509335
Name:GORDON, HYACINTH D (PA)
Entity Type:Individual
Prefix:MRS
First Name:HYACINTH
Middle Name:D
Last Name:GORDON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 EVERGREEN AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11221-3846
Mailing Address - Country:US
Mailing Address - Phone:917-902-2220
Mailing Address - Fax:
Practice Address - Street 1:8825 153RD ST STE 4F
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-3748
Practice Address - Country:US
Practice Address - Phone:718-523-3260
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004032-1363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical