MEDICARE: DINAMARIE GORDON R.N.

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	163W00000X	Registered Nurse	673259	NY

General Provider Information

NPI Number	:	1518382548
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DINAMARIE GORDON R.N.

Provider Business Mailing Address
First Line	:	18 BIRCHWOOD DR
Second Line	:
City	:	PORT JEFFERSON STATION
State	:	NY
Zip	:	11776-3538
Country	:	US
Telephone Number	:	631-682-4852
Fax Number	:

Provider Business Practice Location Address
First Line	:	18 BIRCHWOOD DR
Second Line	:
City	:	PORT JEFFERSON STATION
State	:	NY
Zip	:	11776-3538
Country	:	US
Telephone Number	:	631-682-4852
Fax Number	:

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

Provider Enumeration Date	:	02/27/2014
Last Update Date	:	02/27/2014

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