Provider Demographics
NPI:1225562622
Name:GORDON, MICHAEL D (APRN)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:GORDON
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:MICHAEL
Other - Middle Name:D
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN
Mailing Address - Street 1:373 BREEZEEL SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:KY
Mailing Address - Zip Code:42025-5376
Mailing Address - Country:US
Mailing Address - Phone:270-703-7320
Mailing Address - Fax:
Practice Address - Street 1:373 BREEZEEL SCHOOL RD
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:KY
Practice Address - Zip Code:42025-5376
Practice Address - Country:US
Practice Address - Phone:307-247-3661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-12
Last Update Date:2021-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3011246364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100515830Medicaid