MEDICARE: DOREEN GORDON FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	201908803NP-PP	OR

General Provider Information

NPI Number	:	1083257109
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOREEN GORDON FNP

Provider Business Mailing Address
First Line	:	1585 NW WASHINGTON BLVD
Second Line	:
City	:	GRANTS PASS
State	:	OR
Zip	:	97526-1049
Country	:	US
Telephone Number	:	541-474-5511
Fax Number	:

Provider Business Practice Location Address
First Line	:	1585 NW WASHINGTON BLVD
Second Line	:
City	:	GRANTS PASS
State	:	OR
Zip	:	97526-1049
Country	:	US
Telephone Number	:	541-474-5511
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/21/2019
Last Update Date	:	12/10/2019

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