Provider Demographics
NPI:1538436670
Name:GORDON, CLARA (PA-C)
Entity type:Individual
Prefix:
First Name:CLARA
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1460
Mailing Address - Street 2:
Mailing Address - City:TRUCKEE
Mailing Address - State:CA
Mailing Address - Zip Code:96160-1460
Mailing Address - Country:US
Mailing Address - Phone:207-577-1809
Mailing Address - Fax:
Practice Address - Street 1:10121 PINE AVE
Practice Address - Street 2:
Practice Address - City:TRUCKEE
Practice Address - State:CA
Practice Address - Zip Code:96161-4856
Practice Address - Country:US
Practice Address - Phone:530-587-6011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA2351363A00000X
MEPA2308363A00000X
MA1102870133V00000X
CAPA52487363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered