Healthcare Provider Details

I. General information

NPI: 1215677133
Provider Name (Legal Business Name): HANNAH MARIE GORDON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2022
Last Update Date: 06/23/2025
Certification Date: 06/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4414 LAKE BOONE TRL STE 103
RALEIGH NC
27607-7520
US

IV. Provider business mailing address

4414 LAKE BOONE TRL STE 103
RALEIGH NC
27607-7520
US

V. Phone/Fax

Practice location:
  • Phone: 919-787-0266
  • Fax: 919-571-9314
Mailing address:
  • Phone: 919-787-0266
  • Fax: 919-571-9314

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2025-01411
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: