Basic Information
Provider Information | |||||||||
NPI: | 1548295322 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GORDON | ||||||||
FirstName: | STANLEY | ||||||||
MiddleName: | RICHARD | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 11960 WINDY OAKS DR E | ||||||||
Address2: |   | ||||||||
City: | GRAND BAY | ||||||||
State: | AL | ||||||||
PostalCode: | 365413125 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2512142384 | ||||||||
FaxNumber: | 2518650098 | ||||||||
Practice Location | |||||||||
Address1: | 2570 HAYMAKER RD | ||||||||
Address2: |   | ||||||||
City: | MONROEVILLE | ||||||||
State: | PA | ||||||||
PostalCode: | 151463513 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4128582843 | ||||||||
FaxNumber: | 4128583190 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/11/2006 | ||||||||
LastUpdateDate: | 07/09/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 051211 | AL | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |   |
ID Information
ID | Type | State | Issuer | Description | 0124687 | 05 | MS |   | MEDICAID |