Provider Demographics
NPI:1962552661
Name:GORDON, TARA ANN (PA)
Entity type:Individual
Prefix:MS
First Name:TARA
Middle Name:ANN
Last Name:GORDON
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:1200 N BEAVER ST
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-3118
Mailing Address - Country:US
Mailing Address - Phone:928-213-6235
Mailing Address - Fax:928-213-6292
Practice Address - Street 1:107 E OAK AVE
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1818
Practice Address - Country:US
Practice Address - Phone:928-779-7880
Practice Address - Fax:928-779-7895
Is Sole Proprietor?:No
Enumeration Date:2007-01-12
Last Update Date:2021-05-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
AZ3598363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZQ76660Medicare UPIN
AZ113809Medicare PIN