Provider Demographics
NPI:1427455831
Name:GORDON, SHAN C (ARNP)
Entity type:Individual
Prefix:MRS
First Name:SHAN
Middle Name:C
Last Name:GORDON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 269084
Mailing Address - Street 2:DEPT 1102
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126
Mailing Address - Country:US
Mailing Address - Phone:731-394-1145
Mailing Address - Fax:
Practice Address - Street 1:867 MCGUIRE AVE
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-4036
Practice Address - Country:US
Practice Address - Phone:731-394-1145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-01
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4007490363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner