Provider Demographics
NPI:1508629890
Name:GORDON, ISABELLA AGNES
Entity Type:Individual
Prefix:
First Name:ISABELLA
Middle Name:AGNES
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 1:3600 GOODWATER ST
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-7643
Mailing Address - Country:US
Mailing Address - Phone:703-217-2061
Mailing Address - Fax:
Practice Address - Street 1:3600 GOODWATER ST
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-7643
Practice Address - Country:US
Practice Address - Phone:703-217-2061
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-31
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant