Provider Demographics
NPI:1568836153
Name:GORDON, ALEXANDER LEONARD (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:LEONARD
Last Name:GORDON
Suffix:
Gender:M
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 NE DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-4617
Mailing Address - Country:US
Mailing Address - Phone:503-666-6575
Mailing Address - Fax:
Practice Address - Street 1:2716 FREEDOM BLVD
Practice Address - Street 2:
Practice Address - City:FREEDOM
Practice Address - State:CA
Practice Address - Zip Code:95019
Practice Address - Country:US
Practice Address - Phone:831-688-6293
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-19
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202206489RN163W00000X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ91892ZOtherSANTA CRUZ COUNTY MEDICARE GROUP PTAN#