Provider Demographics
NPI:1497187744
Name:GORDON, LISA (FNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:FNP
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 1245
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29116-1245
Mailing Address - Country:US
Mailing Address - Phone:803-395-4561
Mailing Address - Fax:803-395-2237
Practice Address - Street 1:1175 COOK RD
Practice Address - Street 2:SUITE 230
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-8201
Practice Address - Country:US
Practice Address - Phone:803-395-3900
Practice Address - Fax:803-395-3920
Is Sole Proprietor?:No
Enumeration Date:2013-08-08
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18441363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily