Provider Demographics
NPI:1497856306
Name:NIELSEN, GORDON KEITH (RPH, PA)
Entity Type:Individual
Prefix:MR
First Name:GORDON
Middle Name:KEITH
Last Name:NIELSEN
Suffix:
Gender:M
Credentials:RPH, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3184 CHURN CREEK RD
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96002-2122
Mailing Address - Country:US
Mailing Address - Phone:530-226-1751
Mailing Address - Fax:530-224-2726
Practice Address - Street 1:3184 CHURN CREEK RD
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96002-2122
Practice Address - Country:US
Practice Address - Phone:530-226-1751
Practice Address - Fax:530-224-2726
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARPH24939183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA13095OtherPHYSICIAN ASSISTANT LIC#
CARPH24939OtherPHARMACIST LICENSE