Provider Demographics
NPI:1346562147
Name:GORDON, KIMBERLY RENEE (PA-C)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:RENEE
Last Name:GORDON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9929 REA RD STE 201
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-6439
Practice Address - Country:US
Practice Address - Phone:704-316-1650
Practice Address - Fax:704-316-1651
Is Sole Proprietor?:No
Enumeration Date:2010-02-20
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9105103363AM0700X
NC0010-07737363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018579700Medicaid
FLY0S1DOtherBCBS
FL018579700Medicaid