Provider Demographics
NPI:1972335024
Name:GORDON, JAMES JOHN (NP)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:JOHN
Last Name:GORDON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10604 SOUTHWEST HWY STE 107
Mailing Address - Street 2:
Mailing Address - City:CHICAGO RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60415-2717
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10604 SOUTHWEST HWY STE 107
Practice Address - Street 2:
Practice Address - City:CHICAGO RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60415-2717
Practice Address - Country:US
Practice Address - Phone:708-422-0636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-16
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.029629363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner