Provider Demographics
NPI:1942895925
Name:GORDON, KEVIN DARELLE (NP)
Entity Type:Individual
Prefix:MR
First Name:KEVIN
Middle Name:DARELLE
Last Name:GORDON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:KEVIN
Other - Middle Name:DARELLE
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:9554 TARBERT DR
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-4478
Mailing Address - Country:US
Mailing Address - Phone:404-384-0439
Mailing Address - Fax:
Practice Address - Street 1:10385 OLD PLACERVILLE RD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95827-2506
Practice Address - Country:US
Practice Address - Phone:916-448-1770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95015623363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner