Provider Demographics
NPI:1467141531
Name:GORDON, RANDALL JR
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:
Last Name:GORDON
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 PARK AVE APT 1L
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550-2151
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:30 PARK AVE APT 1L
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-2151
Practice Address - Country:US
Practice Address - Phone:347-341-9334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-04
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3747P1801X, 172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant