Healthcare Provider Details

I. General information

NPI: 1972756229
Provider Name (Legal Business Name): HEATHER KAY GORDON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2008
Last Update Date: 10/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 NW 170TH ST
NORTH MIAMI BEACH FL
33169-5521
US

IV. Provider business mailing address

2625 COLLINS AVE #1104
MIAMI BEACH FL
33140-4746
US

V. Phone/Fax

Practice location:
  • Phone: 706-495-0431
  • Fax:
Mailing address:
  • Phone: 706-495-0431
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPAT 9104789
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: