Provider Demographics
NPI:1720488950
Name:GORDON, ABBY ILYCE (DPT, EMT)
Entity Type:Individual
Prefix:
First Name:ABBY
Middle Name:ILYCE
Last Name:GORDON
Suffix:
Gender:F
Credentials:DPT, EMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16083 SW UPPER BOONES FERRY RD STE 300
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-7736
Mailing Address - Country:US
Mailing Address - Phone:800-219-8835
Mailing Address - Fax:503-639-9699
Practice Address - Street 1:17901 BOTHELL EVERETT HWY STE F-104
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98012-6387
Practice Address - Country:US
Practice Address - Phone:425-424-3924
Practice Address - Fax:425-424-3941
Is Sole Proprietor?:No
Enumeration Date:2014-08-25
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT17180146N00000X
CT10234225100000X
WA60495067225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2064003Medicaid