Provider Demographics
NPI:1952716250
Name:GORDON, TAYLOR HUGHES
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:HUGHES
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 896206
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-6206
Mailing Address - Country:US
Mailing Address - Phone:252-633-6730
Mailing Address - Fax:252-633-6740
Practice Address - Street 1:960 NEWMAN RD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-5200
Practice Address - Country:US
Practice Address - Phone:252-633-6730
Practice Address - Fax:252-633-6740
Is Sole Proprietor?:No
Enumeration Date:2014-06-25
Last Update Date:2022-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA1562363A00000X
VA0110004638363A00000X
NC0010-12103363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEE400251426Medicare PIN
MEE400251434Medicare PIN