1326563917 NPI number — ALISSA A GORDON APN, DNP

Table of content: ALISSA A GORDON APN, DNP (NPI 1326563917)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326563917 NPI number — ALISSA A GORDON APN, DNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORDON
Provider First Name:
ALISSA
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APN, DNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HUECHTEMAN
Provider Other First Name:
ALISSA
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
APN, DNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1326563917
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/27/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
500 W RIVER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAVENPORT
Provider Business Mailing Address State Name:
IA
Provider Business Mailing Address Postal Code:
52801-1014
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
563-336-3000
Provider Business Mailing Address Fax Number:
563-336-3125

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2750 11TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCK ISLAND
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61201
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
563-336-3000
Provider Business Practice Location Address Fax Number:
563-327-2102
Provider Enumeration Date:
08/04/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LG0600X , with the licence number:  209016237 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1598759292 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1326563917 , issued by the state of ( IA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 132380068 . This is a "IOWA MEDICARE" identifier , issued by the state of ( IA ) . This identifiers is of the category "OTHER".
  • Identifier: F400408026 . This is a "ILLINIOS MEDICARE" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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