Provider Demographics
NPI:1831158351
Name:GORDON, JOHN DAVID (PAC)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:DAVID
Last Name:GORDON
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 E TIOGA AVE STE 102
Mailing Address - Street 2:SMITH ALLERGY & ASTHMA OF CNY PLLC
Mailing Address - City:CORNING
Mailing Address - State:NY
Mailing Address - Zip Code:14830-2858
Mailing Address - Country:US
Mailing Address - Phone:607-684-6115
Mailing Address - Fax:607-684-6120
Practice Address - Street 1:88 E TIOGA AVE STE 102
Practice Address - Street 2:88 TIOGA AVENUE, STE 102
Practice Address - City:CORNING
Practice Address - State:NY
Practice Address - Zip Code:14830-2858
Practice Address - Country:US
Practice Address - Phone:607-684-6115
Practice Address - Fax:607-684-6120
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051642363A00000X
NY004758363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400278137OtherMEDICARE PTAN
PACC9269OtherRR MEDICARE GROUP
PAP00177089OtherRR MEDICARE PIN
PAGU040061OtherMEDICARE GROUP
PA078956N91Medicare PIN
PAP00177089OtherRR MEDICARE PIN