Healthcare Provider Details

I. General information

NPI: 1427673649
Provider Name (Legal Business Name): RONNY KEITH GORDON JR. APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2020
Last Update Date: 12/21/2021
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13509 N MERIDIAN AVE
OKLAHOMA CITY OK
73120-8397
US

IV. Provider business mailing address

475 GRIGSBY ST
NEWCASTLE OK
73065-5950
US

V. Phone/Fax

Practice location:
  • Phone: 405-937-7422
  • Fax: 405-848-3591
Mailing address:
  • Phone: 405-361-9614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR0105864
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: