Provider Demographics
NPI:1336573500
Name:GORDON, AMY R (NP-C)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:R
Last Name:GORDON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55415-1533
Mailing Address - Country:US
Mailing Address - Phone:612-596-9643
Mailing Address - Fax:612-596-9641
Practice Address - Street 1:525 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55415-1533
Practice Address - Country:US
Practice Address - Phone:612-596-9643
Practice Address - Fax:612-596-9641
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-23
Last Update Date:2017-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1830486363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNH400240648Medicaid