Provider Demographics
NPI:1104624535
Name:GORDON, KAYLA (PA-C)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:
Last Name:GORDON
Suffix:
Gender:
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 1:1081 FORESTGLEN DR
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59718-6667
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1307 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-4801
Practice Address - Country:US
Practice Address - Phone:406-792-3001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-PAC-LIC-146532363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant