Provider Demographics
NPI:1508243858
Name:GIDEON, HERNDON (NP)
Entity Type:Individual
Prefix:
First Name:HERNDON
Middle Name:
Last Name:GIDEON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4705 GRACELANN
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74804-2372
Mailing Address - Country:US
Mailing Address - Phone:580-380-1483
Mailing Address - Fax:
Practice Address - Street 1:12 E MACARTHUR ST
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74804-2135
Practice Address - Country:US
Practice Address - Phone:405-275-1001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-06
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK82547363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily