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General NPI Number Information
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NPI Number | 1881049898
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Entity Type | Individual
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Provider Name | ERIC A GORDON
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Gender | Male
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Dates
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Enumeration Date | 04/27/2016
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Last Update Date | 04/15/2020
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Provider Practice Location Address
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Address Line | 6451 BRENTWOOD STAIR RD
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City | FORT WORTH
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State | TX
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Zip | 76112-3200
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Country | US
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Telephone | 817-451-4208
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Fax | 817-563-3699
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Provider Business Mailing Address
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Address Line | PO BOX 24244
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City | FORT WORTH
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State | TX
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Zip | 76124-1244
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Country | US
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Telephone | 817-451-4208
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Fax | 817-563-3699
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA10629
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License Number State | TX
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