Healthcare Provider Details

I. General information

NPI: 1659516870
Provider Name (Legal Business Name): PATRICIA ODOM GORDON FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/03/2008
Last Update Date: 09/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5161 HARRY HINES BLVD
DALLAS TX
75390-9055
US

IV. Provider business mailing address

5161 HARRY HINES BLVD
DALLAS TX
75390-9055
US

V. Phone/Fax

Practice location:
  • Phone: 214-645-2080
  • Fax: 214-645-2092
Mailing address:
  • Phone: 214-645-2080
  • Fax: 214-645-2092

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number761144
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number761144
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: