Healthcare Provider Details

I. General information

NPI: 1568836153
Provider Name (Legal Business Name): ALEXANDER LEONARD GORDON REGISTERED NURSE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2015
Last Update Date: 05/24/2023
Certification Date: 05/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2716 FREEDOM BLVD
FREEDOM CA
95019
US

IV. Provider business mailing address

4101 NE DIVISION ST
GRESHAM OR
97030-4617
US

V. Phone/Fax

Practice location:
  • Phone: 831-688-6293
  • Fax:
Mailing address:
  • Phone: 503-666-6575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number202206489RN
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: