MEDICARE: SAMANTHA GORDON ATC

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	2255A2300X	Athletic Trainer

General Provider Information

NPI Number	:	1750954509
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMANTHA GORDON ATC

Provider Business Mailing Address
First Line	:	4515 S 24TH DR
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85041-2011
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3434 S 67TH AVE
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85043-6523
Country	:	US
Telephone Number	:	623-474-7700
Fax Number	:

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

Provider Enumeration Date	:	07/20/2021
Last Update Date	:	07/20/2021

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