Provider Demographics
NPI:1609863182
Name:GORDON, MARY E (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:E
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 1:325E KENNEDY MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:WATERVILLE
Mailing Address - State:ME
Mailing Address - Zip Code:04901-4531
Mailing Address - Country:US
Mailing Address - Phone:207-873-5665
Mailing Address - Fax:207-873-5545
Practice Address - Street 1:325E KENNEDY MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:WATERVILLE
Practice Address - State:ME
Practice Address - Zip Code:04901-4531
Practice Address - Country:US
Practice Address - Phone:207-873-5665
Practice Address - Fax:207-873-5545
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MER016730363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME040648OtherANTHEM
ME39369OtherHARVARD PILGRIM HEALTHCAR
MENP3764Medicare PIN
MEP56008Medicare UPIN