Provider Demographics
NPI:1306377023
Name:GORDON, ANDREA ALEXIS (APNP)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:ALEXIS
Last Name:GORDON
Suffix:
Gender:F
Credentials:APNP
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:ALEXIS
Other - Last Name:GALLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6308 8TH AVENUE, STE 202
Mailing Address - Street 2:
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-5031
Mailing Address - Country:US
Mailing Address - Phone:262-653-5330
Mailing Address - Fax:262-653-5346
Practice Address - Street 1:6308 8TH AVENUE
Practice Address - Street 2:STE 202
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143
Practice Address - Country:US
Practice Address - Phone:262-653-5330
Practice Address - Fax:262-653-5346
Is Sole Proprietor?:No
Enumeration Date:2017-03-23
Last Update Date:2018-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI178314-030163W00000X
WI8432-33363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI8432-33OtherWI LICENSE
WI1306377023Medicaid