Provider Demographics
NPI:1588777858
Name:GORDON, SAFIYA A (ARNP)
Entity type:Individual
Prefix:MS
First Name:SAFIYA
Middle Name:A
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 1:3040 36TH AVE S
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33712-3731
Mailing Address - Country:US
Mailing Address - Phone:727-320-7879
Mailing Address - Fax:
Practice Address - Street 1:9900 BREN RD E
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55343-9664
Practice Address - Country:US
Practice Address - Phone:727-320-7879
Practice Address - Fax:727-320-7879
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9176677363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLQ38406Medicare UPIN
FLU4343ZMedicare ID - Type Unspecified