Provider Demographics
NPI:1467605352
Name:GORDON, SHIRLEY L
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:L
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 4907
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59806
Mailing Address - Country:US
Mailing Address - Phone:406-541-3918
Mailing Address - Fax:406-541-3813
Practice Address - Street 1:120 S 5TH ST
Practice Address - Street 2:STE 104
Practice Address - City:HAMILTON
Practice Address - State:MT
Practice Address - Zip Code:59840-1200
Practice Address - Country:US
Practice Address - Phone:406-541-3918
Practice Address - Fax:406-541-3813
Is Sole Proprietor?:No
Enumeration Date:2008-10-23
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician