Provider Demographics
NPI:1922017441
Name:GORDON, LINDA
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1102 W INDIANTOWN RD STE 7
Mailing Address - Street 2:
Mailing Address - City:JUPITER
Mailing Address - State:FL
Mailing Address - Zip Code:33458-6813
Mailing Address - Country:US
Mailing Address - Phone:412-965-0692
Mailing Address - Fax:
Practice Address - Street 1:1102 W INDIANTOWN RD STE 7
Practice Address - Street 2:
Practice Address - City:JUPITER
Practice Address - State:FL
Practice Address - Zip Code:33458-6813
Practice Address - Country:US
Practice Address - Phone:412-965-0692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2021-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN235479207RC0000X
PAVP000749A363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1922017441Medicaid
PA102242273Medicaid