Provider Demographics
NPI:1548786858
Name:DUVALL, GORDON EDWARD
Entity type:Individual
Prefix:
First Name:GORDON
Middle Name:EDWARD
Last Name:DUVALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 S ROLLIE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LUPTON
Mailing Address - State:CO
Mailing Address - Zip Code:80621-1508
Mailing Address - Country:US
Mailing Address - Phone:303-892-6401
Mailing Address - Fax:303-286-4589
Practice Address - Street 1:562 SABLE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:CO
Practice Address - Zip Code:80011-0809
Practice Address - Country:US
Practice Address - Phone:036-972-5833
Practice Address - Fax:303-286-4589
Is Sole Proprietor?:No
Enumeration Date:2017-08-17
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.00032022080A0000X
CO0003202363LP0200X
COAPN.0003202-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics