Provider Demographics
NPI:1174897524
Name:GORDON, MICHELLE L
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name: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 1:1409 CRAIG BLVD
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73003-3135
Mailing Address - Country:US
Mailing Address - Phone:405-248-1155
Mailing Address - Fax:
Practice Address - Street 1:1409 CRAIG BLVD
Practice Address - Street 2:
Practice Address - City:EDMOND
Practice Address - State:OK
Practice Address - Zip Code:73003-3135
Practice Address - Country:US
Practice Address - Phone:405-248-1155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-02
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor