Provider Demographics
NPI:1417972837
Name:GORDON, LAWRENCE A (MD)
Entity Type:Individual
Prefix:DR
First Name:LAWRENCE
Middle Name:A
Last Name:GORDON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:LARRY
Other - Middle Name:A
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 850
Mailing Address - Street 2:
Mailing Address - City:PORT ANGELES
Mailing Address - State:WA
Mailing Address - Zip Code:98362-0146
Mailing Address - Country:US
Mailing Address - Phone:360-565-9240
Mailing Address - Fax:360-565-9241
Practice Address - Street 1:939 CAROLINE ST
Practice Address - Street 2:
Practice Address - City:PORT ANGELES
Practice Address - State:WA
Practice Address - Zip Code:98362-3909
Practice Address - Country:US
Practice Address - Phone:360-417-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00027956207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAC97410Medicare UPIN
WA1061373Medicaid