Provider Demographics
NPI:1457329641
Name:GORDON, LANDIS COFFEE (PA-C)
Entity Type:Individual
Prefix:
First Name:LANDIS
Middle Name:COFFEE
Last Name:GORDON
Suffix:
Gender:F
Credentials:PA-C
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 2650
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31793-2650
Mailing Address - Country:US
Mailing Address - Phone:229-353-3422
Mailing Address - Fax:229-391-4059
Practice Address - Street 1:2227 US HIGHWAY 41 N
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-2749
Practice Address - Country:US
Practice Address - Phone:229-386-5222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003887363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100002324AMedicaid
FL291289900Medicaid
GA970027360Medicare PIN
P58974Medicare UPIN
GA100002324AMedicaid