Healthcare Provider Details

I. General information

NPI: 1538647698
Provider Name (Legal Business Name): JONATHAN GORDON NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2018
Last Update Date: 08/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1419 GRANDE MESA DR
GEORGETOWN TX
78626-7079
US

IV. Provider business mailing address

1419 GRANDE MESA DR
GEORGETOWN TX
78626-7079
US

V. Phone/Fax

Practice location:
  • Phone: 512-589-4599
  • Fax:
Mailing address:
  • Phone: 512-589-4599
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number841626
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP138312
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: