Provider Demographics
NPI:1558678144
Name:GORDON, STEFANIE B (PA-C)
Entity type:Individual
Prefix:
First Name:STEFANIE
Middle Name:B
Last Name:GORDON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 MILL RD
Mailing Address - Street 2:
Mailing Address - City:HAVERTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19083-3725
Mailing Address - Country:US
Mailing Address - Phone:610-368-4387
Mailing Address - Fax:
Practice Address - Street 1:822 PINE ST STE 4B
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-6187
Practice Address - Country:US
Practice Address - Phone:215-829-8110
Practice Address - Fax:215-829-8119
Is Sole Proprietor?:No
Enumeration Date:2010-09-03
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA054525363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1134439037Medicaid