Provider Demographics
NPI:1356335657
Name:GORDAN, CAROLYN DOUGHTY (PNP)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:DOUGHTY
Last Name:GORDAN
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1046 E WENDOVER AVE
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-6712
Mailing Address - Country:US
Mailing Address - Phone:336-272-1050
Mailing Address - Fax:336-272-0155
Practice Address - Street 1:433 W MEADOWVIEW RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27406-4316
Practice Address - Country:US
Practice Address - Phone:336-370-9091
Practice Address - Fax:336-370-4922
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC300060363L00000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCZN000012Medicaid