Healthcare Provider Details

I. General information

NPI: 1487130589
Provider Name (Legal Business Name): JOHN GORDON APN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2018
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 JOEL DR
FORT CAMPBELL KY
42223-8355
US

IV. Provider business mailing address

650 JOEL DR
FORT CAMPBELL KY
42223-8355
US

V. Phone/Fax

Practice location:
  • Phone: 270-798-8400
  • Fax:
Mailing address:
  • Phone: 270-798-8400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAPN24180
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: