Provider Demographics
NPI:1891961298
Name:ROSS, GORDON KEITH
Entity Type:Individual
Prefix:
First Name:GORDON
Middle Name:KEITH
Last Name:ROSS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 608
Mailing Address - Street 2:
Mailing Address - City:KNOX CITY
Mailing Address - State:TX
Mailing Address - Zip Code:79529-0608
Mailing Address - Country:US
Mailing Address - Phone:940-657-3535
Mailing Address - Fax:940-657-3005
Practice Address - Street 1:701 SE 5TH ST
Practice Address - Street 2:
Practice Address - City:KNOX CITY
Practice Address - State:TX
Practice Address - Zip Code:79529-0608
Practice Address - Country:US
Practice Address - Phone:940-657-3535
Practice Address - Fax:940-657-3005
Is Sole Proprietor?:No
Enumeration Date:2008-05-06
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX662304163WC0200X, 163WD0400X, 163WE0003X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
No163WE0003XNursing Service ProvidersRegistered NurseEmergency