Provider Demographics
NPI:1407843642
Name:GORDY, TERESA PIRTLE (CRNA)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:PIRTLE
Last Name:GORDY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MRS
Other - First Name:TERESA
Other - Middle Name:LINN
Other - Last Name:GORDY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3532 STEVENS WAY
Mailing Address - Street 2:
Mailing Address - City:MARTINEZ
Mailing Address - State:GA
Mailing Address - Zip Code:30907-8901
Mailing Address - Country:US
Mailing Address - Phone:706-228-5491
Mailing Address - Fax:
Practice Address - Street 1:302 UNIVERSITY PKWY
Practice Address - Street 2:AIKEN REGIONAL MEDICAL CENTER
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-6302
Practice Address - Country:US
Practice Address - Phone:803-641-5489
Practice Address - Fax:803-641-5148
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCR94915367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN1302Medicaid
SCAN1302Medicaid