Provider Demographics
NPI:1497782528
Name:GORDON, TINA T (CRNA)
Entity Type:Individual
Prefix:MISS
First Name:TINA
Middle Name:T
Last Name:GORDON
Suffix:
Gender:F
Credentials:CRNA
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 8626
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99203-0626
Mailing Address - Country:US
Mailing Address - Phone:509-939-9722
Mailing Address - Fax:509-228-9542
Practice Address - Street 1:104 W 5TH AVE
Practice Address - Street 2:SUITE 205E
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-4880
Practice Address - Country:US
Practice Address - Phone:509-939-9722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00106322367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA9624115Medicaid
WAGAB27115Medicare ID - Type Unspecified