Provider Demographics
NPI:1346546199
Name:GORDON, PATRICIA (PT)
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:429 LAKE BARNEGAT DR N
Mailing Address - Street 2:
Mailing Address - City:FORKED RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08731-1621
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9 MULE RD
Practice Address - Street 2:E2
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-5043
Practice Address - Country:US
Practice Address - Phone:732-473-1666
Practice Address - Fax:732-473-1601
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-26
Last Update Date:2011-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00422000174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty