=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811726375
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHIRLEY GORDON RRT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2024
-----------------------------------------------------
Last Update Date | 07/31/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2201 SE LOOP 820
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76119-5863
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-730-1000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4445 CORNER BROOK LN
-----------------------------------------------------
City | FORT WORTH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76123-2733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-919-1608
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2279G1100X
-----------------------------------------------------
Taxonomy Name | General Care Registered Respiratory Therapist
-----------------------------------------------------
License Number | RCP00066728
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 227900000X
-----------------------------------------------------
Taxonomy Name | Registered Respiratory Therapist
-----------------------------------------------------
License Number | RCP00066728
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------