Provider Demographics
NPI:1659784809
Name:GORDON, ODELL DELROY (NP)
Entity Type:Individual
Prefix:MR
First Name:ODELL
Middle Name:DELROY
Last Name:GORDON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:40 HURLEY AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:KINGSTON
Mailing Address - State:NY
Mailing Address - Zip Code:12401-3739
Mailing Address - Country:US
Mailing Address - Phone:845-338-5600
Mailing Address - Fax:845-338-3058
Practice Address - Street 1:40 HURLEY AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-3739
Practice Address - Country:US
Practice Address - Phone:845-338-5600
Practice Address - Fax:845-338-3058
Is Sole Proprietor?:No
Enumeration Date:2014-06-05
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF338818-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily