Provider Demographics
NPI:1982031159
Name:GORDON, SANDRA SHEPHERD (PA)
Entity Type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:SHEPHERD
Last Name:GORDON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:SANDRA
Other - Middle Name:LYNN
Other - Last Name:SHEPHERD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:19 BRADHURST AVE STE 3100N
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:NY
Mailing Address - Zip Code:10532-2140
Mailing Address - Country:US
Mailing Address - Phone:914-909-9018
Mailing Address - Fax:
Practice Address - Street 1:85 RETREAT AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-2555
Practice Address - Country:US
Practice Address - Phone:860-972-4183
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-03
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5070363AM0700X
NY017044363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical