MEDICARE: CAROLYN DOUGHTY GORDAN PNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363L00000X	Nurse Practitioner	300060	NC
2	363LP0200X	Pediatric Nurse Practitioner	300060	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356335657
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAROLYN DOUGHTY GORDAN PNP

Provider Business Mailing Address
First Line	:	1046 E WENDOVER AVE
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27405-6712
Country	:	US
Telephone Number	:	336-272-1050
Fax Number	:	336-272-0155

Provider Business Practice Location Address
First Line	:	433 W MEADOWVIEW RD
Second Line	:
City	:	GREENSBORO
State	:	NC
Zip	:	27406-4316
Country	:	US
Telephone Number	:	336-370-9091
Fax Number	:	336-370-4922

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/01/2005
Last Update Date	:	02/28/2011

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