Provider Demographics
NPI:1396814778
Name:GORDON, LUCIUS NMN JR (PA-C)
Entity Type:Individual
Prefix:MR
First Name:LUCIUS
Middle Name:NMN
Last Name:GORDON
Suffix:JR
Gender:M
Credentials:PA-C
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Mailing Address - Street 1:1055 N 500 W ATTN: CREDENTIALING
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-3305
Mailing Address - Country:US
Mailing Address - Phone:801-354-8225
Mailing Address - Fax:801-418-0941
Practice Address - Street 1:5640 S 3500 W
Practice Address - Street 2:
Practice Address - City:ROY
Practice Address - State:UT
Practice Address - Zip Code:84067-9158
Practice Address - Country:US
Practice Address - Phone:801-773-2838
Practice Address - Fax:801-773-3025
Is Sole Proprietor?:No
Enumeration Date:2006-11-07
Last Update Date:2018-03-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
363A00000X
UT10495233-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant