Provider Demographics
NPI:1700422888
Name:GORDON, PAIGE (CRNP)
Entity Type:Individual
Prefix:
First Name:PAIGE
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1962 CHEROKEE RD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDER CITY
Mailing Address - State:AL
Mailing Address - Zip Code:35010-3437
Mailing Address - Country:US
Mailing Address - Phone:256-234-5021
Mailing Address - Fax:
Practice Address - Street 1:1962 CHEROKEE RD
Practice Address - Street 2:
Practice Address - City:ALEXANDER CITY
Practice Address - State:AL
Practice Address - Zip Code:35010-3437
Practice Address - Country:US
Practice Address - Phone:256-234-5021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-22
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-159500363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1700422888Medicaid