Provider Demographics
NPI:1629278460
Name:GORDON, JULIE CHRISTINE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:JULIE
Middle Name:CHRISTINE
Last Name:GORDON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:JULIE
Other - Middle Name:CHRISTINE
Other - Last Name:FAIRBANKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:729 W WILSHIRE AVE
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832-1661
Mailing Address - Country:US
Mailing Address - Phone:949-370-0796
Mailing Address - Fax:
Practice Address - Street 1:729 W WILSHIRE AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-1661
Practice Address - Country:US
Practice Address - Phone:949-370-0796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19274363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant