Basic Information
| Provider Information | |||||||||
| NPI: | 1770906539 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | IAN | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4120 W MEMORIAL RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731209320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057483300 | ||||||||
| FaxNumber: | 4057491671 | ||||||||
| Practice Location | |||||||||
| Address1: | 4120 W MEMORIAL RD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 731209320 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4057483300 | ||||||||
| FaxNumber: | 4057491671 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2014 | ||||||||
| LastUpdateDate: | 06/12/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2358 | OK | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 2358 | OK | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | 2358 | OK | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.