Provider Demographics
NPI:1689659690
Name:GORDON, PAUL V (PA-C)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:V
Last Name:GORDON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2434 W BELVEDERE AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215-5202
Mailing Address - Country:US
Mailing Address - Phone:410-601-2246
Mailing Address - Fax:
Practice Address - Street 1:2434 W BELVEDERE AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21215-5202
Practice Address - Country:US
Practice Address - Phone:410-601-2246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2010-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002631363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS589Medicare PIN
MD181390Y8SMedicare PIN
MDH330E821Medicare UPIN
MDP70007Medicare UPIN