Provider Demographics
NPI:1982336319
Name:GORDON, WYATTE
Entity Type:Individual
Prefix:
First Name:WYATTE
Middle Name:
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 1:1221 PRINCETON DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-2616
Mailing Address - Country:US
Mailing Address - Phone:505-310-2434
Mailing Address - Fax:
Practice Address - Street 1:2100 LOUISIANA BLVD NE STE 410
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-5412
Practice Address - Country:US
Practice Address - Phone:505-724-4300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-24
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2023-0298363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant