Provider Demographics
NPI:1902228786
Name:GORDON, SAMANTHA (PA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 EAGLES NEST DR
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27712-2990
Mailing Address - Country:US
Mailing Address - Phone:919-356-1278
Mailing Address - Fax:
Practice Address - Street 1:1811 PHILLIPS DR
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330
Practice Address - Country:US
Practice Address - Phone:919-356-1278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-13
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-04730363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant