Provider Demographics
NPI:1518638428
Name:GORDON, SIMONE ANTOINETTE
Entity Type:Individual
Prefix:
First Name:SIMONE
Middle Name:ANTOINETTE
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:PO BOX 604050
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-4050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9101 PINEVILLE MATTHEWS RD # C4
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28134-8840
Practice Address - Country:US
Practice Address - Phone:980-202-7920
Practice Address - Fax:980-301-9830
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-22
Last Update Date:2023-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCF03210140363LF0000X
NC5017312363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily