Provider Demographics
NPI:1821484452
Name:GORDON, LOUISSA CAROLYN (PA-C)
Entity Type:Individual
Prefix:
First Name:LOUISSA
Middle Name:CAROLYN
Last Name:GORDON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LOUISSA
Other - Middle Name:C
Other - Last Name:SAUTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:777 N RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9251
Mailing Address - Country:US
Mailing Address - Phone:208-514-2500
Mailing Address - Fax:208-375-2217
Practice Address - Street 1:121 E FORT ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83712-6322
Practice Address - Country:US
Practice Address - Phone:208-514-2525
Practice Address - Fax:208-375-2217
Is Sole Proprietor?:No
Enumeration Date:2015-04-10
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60549072363A00000X
IDPA-1772363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant