Provider Demographics
NPI:1255579330
Name:GORDON, PHOEBE (MT)
Entity type:Individual
Prefix:
First Name:PHOEBE
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 PINE KNOLL DR
Mailing Address - Street 2:APT 324
Mailing Address - City:RIDGELAND
Mailing Address - State:MS
Mailing Address - Zip Code:39157-1350
Mailing Address - Country:US
Mailing Address - Phone:601-940-0043
Mailing Address - Fax:
Practice Address - Street 1:109 PINE KNOLL DR
Practice Address - Street 2:APT 324
Practice Address - City:RIDGELAND
Practice Address - State:MS
Practice Address - Zip Code:39157-1350
Practice Address - Country:US
Practice Address - Phone:601-940-0043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-28
Last Update Date:2009-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246QB0000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyBlood Banking