Healthcare Provider Details

I. General information

NPI: 1922569409
Provider Name (Legal Business Name): MS. IGNACIA ALEX GORDON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/27/2019
Last Update Date: 03/27/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11801 NE 65TH ST # A
VANCOUVER WA
98662-5527
US

IV. Provider business mailing address

11801 NE 65TH ST # A
VANCOUVER WA
98662-5527
US

V. Phone/Fax

Practice location:
  • Phone: 360-558-5790
  • Fax: 360-558-5791
Mailing address:
  • Phone: 360-558-5790
  • Fax: 360-558-5791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberCG60568892
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: