MEDICARE: NICKITA GORDON

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	164W00000X	Licensed Practical Nurse	PN309777	PA

General Provider Information

NPI Number	:	1679499933
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICKITA GORDON

Provider Business Mailing Address
First Line	:	6323 TROTTER ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19111-5841
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6323 TROTTER ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19111-5841
Country	:	US
Telephone Number	:	215-543-2876
Fax Number	:

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

Provider Enumeration Date	:	06/29/2026
Last Update Date	:	06/29/2026

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