Provider Demographics
NPI:1285764431
Name:GORDON, ROBERT GEORGE (LMP)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:GEORGE
Last Name:GORDON
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3806 9TH ST SW STE C
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-3687
Mailing Address - Country:US
Mailing Address - Phone:253-770-6658
Mailing Address - Fax:253-770-8766
Practice Address - Street 1:3806 9TH ST SW STE C
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-3687
Practice Address - Country:US
Practice Address - Phone:253-770-6658
Practice Address - Fax:253-770-8766
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00009057225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0182738OtherLABOR AND INDUSTRIES