Provider Demographics
NPI:1770906539
Name:GORDON, IAN (PA)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:GORDON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4120 W MEMORIAL RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-9320
Mailing Address - Country:US
Mailing Address - Phone:405-748-3300
Mailing Address - Fax:405-749-1671
Practice Address - Street 1:4120 W MEMORIAL RD
Practice Address - Street 2:SUITE 300
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-9320
Practice Address - Country:US
Practice Address - Phone:405-748-3300
Practice Address - Fax:405-749-1671
Is Sole Proprietor?:No
Enumeration Date:2014-01-30
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2358363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical