Provider Demographics
NPI:1134943640
Name:GORDONCILLO, RYAN RAE
Entity type:Individual
Prefix:
First Name:RYAN RAE
Middle Name:
Last Name:GORDONCILLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 21
Mailing Address - Street 2:
Mailing Address - City:BURLINGHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12722-0021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 21
Practice Address - Street 2:
Practice Address - City:BURLINGHAM
Practice Address - State:NY
Practice Address - Zip Code:12722-0021
Practice Address - Country:US
Practice Address - Phone:845-630-9209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-12
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY35180801164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse