Provider Demographics
NPI:1013101161
Name:GORDON, KENYETTA MICHELLE (MD)
Entity Type:Individual
Prefix:DR
First Name:KENYETTA
Middle Name:MICHELLE
Last Name:GORDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 WEEOT WAY
Mailing Address - Street 2:
Mailing Address - City:ARCATA
Mailing Address - State:CA
Mailing Address - Zip Code:95521-4734
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1675 NORTHCREST DR
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-8928
Practice Address - Country:US
Practice Address - Phone:707-464-2750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-31
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV19863207Q00000X
ARE-6423207Q00000X
CAC186176207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1013101161Medicaid
NV19863OtherSTATE LICENSE