Provider Demographics
NPI:1841477726
Name:GORDON, DIANE KRAMER (RN,MSN,CPNP)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:KRAMER
Last Name:GORDON
Suffix:
Gender:F
Credentials:RN,MSN,CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 OPELOUSAS ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601-2641
Mailing Address - Country:US
Mailing Address - Phone:337-439-9983
Mailing Address - Fax:337-310-1161
Practice Address - Street 1:500 PATTERSON ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70501-1849
Practice Address - Country:US
Practice Address - Phone:337-439-9983
Practice Address - Fax:337-310-1161
Is Sole Proprietor?:No
Enumeration Date:2008-01-23
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024000058208000000X
LAAP06671363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2164660Medicaid
LA257147YJA2Medicare PIN