Provider Demographics
NPI:1609801505
Name:GORDON, JO R (APRN, BC)
Entity Type:Individual
Prefix:
First Name:JO
Middle Name:R
Last Name:GORDON
Suffix:
Gender:F
Credentials:APRN, BC
Other - Prefix:MS
Other - First Name:JO
Other - Middle Name:R
Other - Last Name:BRADLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP, MS
Mailing Address - Street 1:421 SE MAIN ST # UT100
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-2695
Mailing Address - Country:US
Mailing Address - Phone:864-963-0045
Mailing Address - Fax:
Practice Address - Street 1:421 SE MAIN ST # UT100
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-2695
Practice Address - Country:US
Practice Address - Phone:864-963-0045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5007192363L00000X, 363LF0000X
SC2662363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1892FOtherBCBS NC
NC1609801505Medicaid
SCNP1097Medicaid
NC1892FOtherBCBS NC
SCSC8937E243Medicare PIN