Provider Demographics
NPI:1528701406
Name:LEASE-GORDON, AMBER LYNNE
Entity type:Individual
Prefix:MS
First Name:AMBER
Middle Name:LYNNE
Last Name:LEASE-GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1223E NATIONAL HWY
Mailing Address - Street 2:
Mailing Address - City:LAVALE
Mailing Address - State:MD
Mailing Address - Zip Code:21502-7602
Mailing Address - Country:US
Mailing Address - Phone:240-807-8340
Mailing Address - Fax:
Practice Address - Street 1:1223E NATIONAL HWY
Practice Address - Street 2:
Practice Address - City:LAVALE
Practice Address - State:MD
Practice Address - Zip Code:21502-7602
Practice Address - Country:US
Practice Address - Phone:240-807-8340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-18
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD1528701406207PT0002X
246RP1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No207PT0002XAllopathic & Osteopathic PhysiciansEmergency MedicineMedical Toxicology