Provider Demographics
NPI:1194568683
Name:GORDON, SHIMEAL
Entity type:Individual
Prefix:
First Name:SHIMEAL
Middle Name:
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 1:9530 COSNER DR STE 200
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22408-7760
Mailing Address - Country:US
Mailing Address - Phone:540-373-1331
Mailing Address - Fax:
Practice Address - Street 1:9530 COSNER DR STE 200
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22408-7760
Practice Address - Country:US
Practice Address - Phone:540-373-1331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-13
Last Update Date:2025-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001289844163WH0200X
VA0024193790363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WH0200XNursing Service ProvidersRegistered NurseHome Health