Healthcare Provider Details

I. General information

NPI: 1497782528
Provider Name (Legal Business Name): TINA T GORDON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 W 5TH AVE SUITE 205E
SPOKANE WA
99204-4880
US

IV. Provider business mailing address

PO BOX 8626
SPOKANE WA
99203-0626
US

V. Phone/Fax

Practice location:
  • Phone: 509-939-9722
  • Fax:
Mailing address:
  • Phone: 509-939-9722
  • Fax: 509-228-9542

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN00106322
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: