Provider Demographics
NPI:1356018436
Name:VAN GORDEN, ELISE MARIE (FNP)
Entity type:Individual
Prefix:MRS
First Name:ELISE
Middle Name:MARIE
Last Name:VAN GORDEN
Suffix:
Gender:
Credentials:FNP
Other - Prefix:MISS
Other - First Name:ELISE
Other - Middle Name:MARIE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:295 WILLIAMS RD
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13830-3221
Mailing Address - Country:US
Mailing Address - Phone:607-644-5857
Mailing Address - Fax:607-371-7009
Practice Address - Street 1:295 WILLIAMS RD
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:NY
Practice Address - Zip Code:13830-3221
Practice Address - Country:US
Practice Address - Phone:607-644-5857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-25
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY348256363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty