Provider Demographics
NPI:1568093003
Name:GORDON, YASHI (NP)
Entity Type:Individual
Prefix:
First Name:YASHI
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 MAPLE LN
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-1027
Mailing Address - Country:US
Mailing Address - Phone:917-406-0638
Mailing Address - Fax:
Practice Address - Street 1:1619 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-7412
Practice Address - Country:US
Practice Address - Phone:646-416-5752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-03
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY345295363LF0000X
NYF34529501363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty