1356018436 NPI number — MRS. ELISE MARIE VAN GORDEN FNP

Table of content: MRS. ELISE MARIE VAN GORDEN FNP (NPI 1356018436)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356018436 NPI number — MRS. ELISE MARIE VAN GORDEN FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VAN GORDEN
Provider First Name:
ELISE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILLIAMS
Provider Other First Name:
ELISE
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
FNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1356018436
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/25/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
295 WILLIAMS RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OXFORD
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13830-3221
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-644-5857
Provider Business Mailing Address Fax Number:
607-371-7009

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
295 WILLIAMS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OXFORD
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13830-3221
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-644-5857
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/25/2021

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: 363LF0000X , with the licence number:  348256 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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