Provider Demographics
NPI:1518263342
Name:GORDON, NORMA
Entity Type:Individual
Prefix:
First Name:NORMA
Middle Name:
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 1:1265 UPPER HEMBREE RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-1257
Mailing Address - Country:US
Mailing Address - Phone:770-751-1133
Mailing Address - Fax:770-751-7410
Practice Address - Street 1:1265 UPPER HEMBREE RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-1257
Practice Address - Country:US
Practice Address - Phone:770-751-1133
Practice Address - Fax:770-751-7410
Is Sole Proprietor?:No
Enumeration Date:2011-01-26
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001468363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant