Provider Demographics
NPI:1982789939
Name:GORDON, NICOLE (NP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:ROGALSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:138 WEBSTER ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03104-2512
Mailing Address - Country:US
Mailing Address - Phone:603-663-7030
Mailing Address - Fax:603-663-7039
Practice Address - Street 1:138 WEBSTER ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03104-2512
Practice Address - Country:US
Practice Address - Phone:603-663-7030
Practice Address - Fax:603-663-7039
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA254623363L00000X, 363LG0600X
NH053134-23363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0700576Medicaid
MAQ20604Medicare UPIN
MA0700576Medicaid