Provider Demographics
NPI:1245356393
Name:GORDON, JOELLEN (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:JOELLEN
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 W DR MLK BLVD
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-6306
Mailing Address - Country:US
Mailing Address - Phone:813-877-8450
Mailing Address - Fax:
Practice Address - Street 1:6821 W HILLSBOROUGH AVE
Practice Address - Street 2:STE #19
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33634-5003
Practice Address - Country:US
Practice Address - Phone:813-890-0705
Practice Address - Fax:813-890-0710
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 2812363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA 2812OtherPHYSICIAN ASSISTANT