Healthcare Provider Details

I. General information

NPI: 1699838490
Provider Name (Legal Business Name): JAY M. GORDON R. N.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6666 S SHERIDAN RD
TULSA OK
74133-1756
US

IV. Provider business mailing address

2809 E OAKRIDGE ST
BROKEN ARROW OK
74014-5008
US

V. Phone/Fax

Practice location:
  • Phone: 918-493-2727
  • Fax: 918-493-2990
Mailing address:
  • Phone: 918-258-8571
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License NumberR0070280
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: