Provider Demographics
NPI:1942833595
Name:GORDON, PHILLIP BRANDON
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:BRANDON
Last Name:GORDON
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 1:2128 GARY ST
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30904-3573
Mailing Address - Country:US
Mailing Address - Phone:478-501-3199
Mailing Address - Fax:
Practice Address - Street 1:1120 15TH ST # GC5110
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:706-721-2251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-21
Last Update Date:2020-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GADN016102390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program