Provider Demographics
NPI:1518934199
Name:GORDON, MARCIA SMITH (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:MARCIA
Middle Name:SMITH
Last Name:GORDON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1632 116TH AVE NE
Mailing Address - Street 2:SUITE B
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3035
Mailing Address - Country:US
Mailing Address - Phone:425-454-7546
Mailing Address - Fax:425-637-8133
Practice Address - Street 1:1632 116TH AVE NE
Practice Address - Street 2:SUITE B
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3035
Practice Address - Country:US
Practice Address - Phone:425-454-7546
Practice Address - Fax:425-637-8133
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30001573363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP60456Medicare UPIN