Provider Demographics
NPI:1912918731
Name:GORDON, JAMES (PA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 ELLENFIELD ST STE 101
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4541
Mailing Address - Country:US
Mailing Address - Phone:401-444-6779
Mailing Address - Fax:
Practice Address - Street 1:245 CHAPMAN ST STE 300
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-4539
Practice Address - Country:US
Practice Address - Phone:401-444-5280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102412363A00000X
RIPA01655363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1912918731Medicaid
SC1580PAMedicaid
NC8102073Medicaid
P28047Medicare UPIN
NC2753140AMedicare PIN
NC1912918731Medicaid
NCNCQ639BMedicare PIN