Provider Demographics
NPI:1699713560
Name:GORDON, DONNA SUE (CRNA)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:SUE
Last Name:GORDON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8507 EMERALD HILL DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-8012
Mailing Address - Country:US
Mailing Address - Phone:512-343-5559
Mailing Address - Fax:
Practice Address - Street 1:8507 EMERALD HILL DR
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78759-8012
Practice Address - Country:US
Practice Address - Phone:512-343-5559
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-03
Last Update Date:2013-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX508138367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX176175102Medicaid
TX85945UOtherBLUE CROSS BLUE SHIELD
TX176175102Medicaid