Provider Demographics
NPI:1124765656
Name:GORDON, ANNA CROW
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:CROW
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 1:1814 COUNTY ROAD 97
Mailing Address - Street 2:
Mailing Address - City:WATER VALLEY
Mailing Address - State:MS
Mailing Address - Zip Code:38965-3430
Mailing Address - Country:US
Mailing Address - Phone:662-816-8730
Mailing Address - Fax:
Practice Address - Street 1:1814 COUNTY ROAD 97
Practice Address - Street 2:
Practice Address - City:WATER VALLEY
Practice Address - State:MS
Practice Address - Zip Code:38965-3430
Practice Address - Country:US
Practice Address - Phone:662-816-8730
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-16
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904651363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner