Provider Demographics
NPI:1134264658
Name:GORDON, ANGELIA M (PA-C)
Entity type:Individual
Prefix:MRS
First Name:ANGELIA
Middle Name:M
Last Name:GORDON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9225 CAPTIVA CIR
Mailing Address - Street 2:
Mailing Address - City:ST PETE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33706-1356
Mailing Address - Country:US
Mailing Address - Phone:727-360-7220
Mailing Address - Fax:
Practice Address - Street 1:9225 CAPTIVA CIR
Practice Address - Street 2:
Practice Address - City:ST PETE BEACH
Practice Address - State:FL
Practice Address - Zip Code:33706-1356
Practice Address - Country:US
Practice Address - Phone:727-360-7220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 3004363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical