Provider Demographics
NPI:1972275055
Name:GORDON, TIMOTHY MICHAEL (EMT- PARAMEDIC)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:MICHAEL
Last Name:GORDON
Suffix:
Gender:M
Credentials:EMT- PARAMEDIC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1497 RIVERS EDGE PKWY
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-6908
Mailing Address - Country:US
Mailing Address - Phone:262-490-4854
Mailing Address - Fax:
Practice Address - Street 1:10233 W GREENFIELD AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53214-3911
Practice Address - Country:US
Practice Address - Phone:414-727-5750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-28
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41348146L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic