Healthcare Provider Details

I. General information

NPI: 1972275055
Provider Name (Legal Business Name): TIMOTHY MICHAEL GORDON EMT- PARAMEDIC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2021
Last Update Date: 09/28/2021
Certification Date: 09/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10233 W GREENFIELD AVE
MILWAUKEE WI
53214-3911
US

IV. Provider business mailing address

1497 RIVERS EDGE PKWY
OCONOMOWOC WI
53066-6908
US

V. Phone/Fax

Practice location:
  • Phone: 414-727-5750
  • Fax:
Mailing address:
  • Phone: 262-490-4854
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146L00000X
TaxonomyParamedic
License Number41348
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: