Provider Demographics
NPI:1427673649
Name:GORDON, RONNY KEITH JR (APRN)
Entity type:Individual
Prefix:
First Name:RONNY
Middle Name:KEITH
Last Name:GORDON
Suffix:JR
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:475 GRIGSBY ST
Mailing Address - Street 2:
Mailing Address - City:NEWCASTLE
Mailing Address - State:OK
Mailing Address - Zip Code:73065-5950
Mailing Address - Country:US
Mailing Address - Phone:405-361-9614
Mailing Address - Fax:
Practice Address - Street 1:13509 N MERIDIAN AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8397
Practice Address - Country:US
Practice Address - Phone:405-937-7422
Practice Address - Fax:405-848-3591
Is Sole Proprietor?:No
Enumeration Date:2020-06-12
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0105864363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily