Provider Demographics
NPI:1821184078
Name:GORDON, BENJAMIN STUART (PA-C)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:STUART
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 1:27699 JEFFERSON AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92590-2661
Mailing Address - Country:US
Mailing Address - Phone:951-252-8588
Mailing Address - Fax:951-252-8589
Practice Address - Street 1:950 N STATE ST
Practice Address - Street 2:BLDG B, SUITE D & E
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543-1485
Practice Address - Country:US
Practice Address - Phone:951-765-1777
Practice Address - Fax:951-765-1772
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17205363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical