Provider Demographics
NPI:1417369000
Name:GORDON, GLORIA NICOLE
Entity Type:Individual
Prefix:MRS
First Name:GLORIA
Middle Name:NICOLE
Last Name:GORDON
Suffix:
Gender:F
Credentials:
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 691258
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74169-1258
Mailing Address - Country:US
Mailing Address - Phone:918-813-6339
Mailing Address - Fax:
Practice Address - Street 1:12222 E 30TH ST
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74129-8423
Practice Address - Country:US
Practice Address - Phone:918-813-6339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-29
Last Update Date:2014-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor