Basic Information
| Provider Information | |||||||||
| NPI: | 1508490079 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | ALICIA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 TIMBER RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | PICKERINGTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 431471173 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7402580644 | ||||||||
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| Practice Location | |||||||||
| Address1: | 18901 LAKE SHORE BLVD | ||||||||
| Address2: | |||||||||
| City: | EUCLID | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441191078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2165319000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2020 | ||||||||
| LastUpdateDate: | 02/24/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/24/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.