Provider Demographics
NPI:1356036826
Name:WALKER, GORDON S JR
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:S
Last Name:WALKER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 PENNSYLVANIA AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:SEAFORD
Mailing Address - State:DE
Mailing Address - Zip Code:19973-3706
Mailing Address - Country:US
Mailing Address - Phone:302-990-8907
Mailing Address - Fax:
Practice Address - Street 1:420 PENNSYLVANIA AVE STE 2
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:DE
Practice Address - Zip Code:19973-3706
Practice Address - Country:US
Practice Address - Phone:302-990-8907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEMC-0003859374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician