Provider Demographics
NPI:1639358831
Name:GORDON, KERRY (MS, ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:MS, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6775 EDMOND ST STE 300
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89118-3502
Mailing Address - Country:US
Mailing Address - Phone:702-205-1315
Mailing Address - Fax:
Practice Address - Street 1:980 KELLY JOHNSON DR
Practice Address - Street 2:SUITE 200
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-3785
Practice Address - Country:US
Practice Address - Phone:702-205-1315
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-24
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC660174400000X
NV0506182174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist