Provider Demographics
NPI:1821169590
Name:GORDON, MARY BURKHART (ARNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BURKHART
Last Name:GORDON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:C
Other - Last Name:BURKHART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:1701 RENAISSANCE BLVD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73013-3086
Mailing Address - Country:US
Mailing Address - Phone:405-844-4978
Mailing Address - Fax:405-844-0562
Practice Address - Street 1:1701 RENAISSANCE BLVD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73013-3086
Practice Address - Country:US
Practice Address - Phone:405-844-4978
Practice Address - Fax:405-844-0562
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS45190363L00000X
OK207906363L00000X
CA95000713363L00000X
AZAP4675363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
6544OtherPHS PROVIDER NUMBER
AZP01137754OtherRAILROAD MEDICARE
FL002828500Medicaid
10001631801OtherCHP PROVIDER NUMBER
MO427250709Medicaid
500028442OtherRR MEDICARE
511800OtherFIRSTGUARD
481202402OtherPSKU TAX ID
AZ757385Medicaid
KS100446630AMedicaid
MO427250709Medicaid
511800OtherFIRSTGUARD
6544OtherPHS PROVIDER NUMBER
AZZ93290Medicare PIN