Provider Demographics
NPI:1740383736
Name:GORDON, KEVIN (PA-C)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 POPLAR CHURCH RD
Mailing Address - Street 2:SUITE 320
Mailing Address - City:CAMP HILL
Mailing Address - State:PA
Mailing Address - Zip Code:17011-2203
Mailing Address - Country:US
Mailing Address - Phone:717-763-7400
Mailing Address - Fax:
Practice Address - Street 1:875 POPLAR CHURCH RD
Practice Address - Street 2:SUITE 320
Practice Address - City:CAMP HILL
Practice Address - State:PA
Practice Address - Zip Code:17011-2203
Practice Address - Country:US
Practice Address - Phone:717-763-7400
Practice Address - Fax:717-909-9566
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA050742363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA028715Medicare ID - Type Unspecified