Healthcare Provider Details

I. General information

NPI: 1073434791
Provider Name (Legal Business Name): KRISTIN LEA GORDON PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5028 BILLY K TRL
MYRTLE BEACH SC
29579-4120
US

IV. Provider business mailing address

5028 BILLY K TRL
MYRTLE BEACH SC
29579-4120
US

V. Phone/Fax

Practice location:
  • Phone: 843-457-9427
  • Fax:
Mailing address:
  • Phone: 843-457-9427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2327
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: