Provider Demographics
NPI:1205990504
Name:WASHINGTON, GORDON RAY (PA)
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:RAY
Last Name:WASHINGTON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:GORDON
Other - Middle Name:RAY
Other - Last Name:WASHINGTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:723 DAFFODIL ST
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN
Mailing Address - State:CO
Mailing Address - Zip Code:80817-4174
Mailing Address - Country:US
Mailing Address - Phone:719-339-0767
Mailing Address - Fax:
Practice Address - Street 1:HHSC STB
Practice Address - Street 2:UNIT #15110
Practice Address - City:CP RED CLOUD
Practice Address - State:REPUBLIC OF KOREA
Practice Address - Zip Code:APO AP 96258
Practice Address - Country:KR
Practice Address - Phone:315-732-7379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1034659363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical