Basic Information
| Provider Information | |||||||||
| NPI: | 1396814778 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORDON | ||||||||
| FirstName: | LUCIUS | ||||||||
| MiddleName: | NMN | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1055 N 500 W ATTN: CREDENTIALING | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846043305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013548225 | ||||||||
| FaxNumber: | 8014180941 | ||||||||
| Practice Location | |||||||||
| Address1: | 5640 S 3500 W | ||||||||
| Address2: | |||||||||
| City: | ROY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 840679158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8017732838 | ||||||||
| FaxNumber: | 8017733025 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/07/2006 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 10495233-1206 | UT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.