Healthcare Provider Details

I. General information

NPI: 1700700408
Provider Name (Legal Business Name): GORDON HEALTH CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 08/25/2026
Certification Date: 08/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10586 SOURWOOD AVE
WALDORF MD
20603
US

IV. Provider business mailing address

10586 SOURWOOD AVE
WALDORF MD
20603-5711
US

V. Phone/Fax

Practice location:
  • Phone: 301-918-5212
  • Fax:
Mailing address:
  • Phone: 301-918-5212
  • Fax: 301-517-9318

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: PATINA GORDON
Title or Position: OWNER
Credential: NP
Phone: 301-918-5212