Provider Demographics
NPI:1346643046
Name:GORDON, JESSICA LYNN (CRNA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:GORDON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:8129 NAVONA LN
Mailing Address - Street 2:
Mailing Address - City:CLAY
Mailing Address - State:NY
Mailing Address - Zip Code:13041-8966
Mailing Address - Country:US
Mailing Address - Phone:315-382-4521
Mailing Address - Fax:
Practice Address - Street 1:301 PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13203-1807
Practice Address - Country:US
Practice Address - Phone:315-299-5451
Practice Address - Fax:315-299-4710
Is Sole Proprietor?:No
Enumeration Date:2014-10-08
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY590938-1163W00000X
NY104815367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY590938-1OtherRN LISENSURE