1801023718 NPI number — KRISTYN LEE GORDON APRN

Table of content: KRISTYN LEE GORDON APRN (NPI 1801023718)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801023718 NPI number — KRISTYN LEE GORDON APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GORDON
Provider First Name:
KRISTYN
Provider Middle Name:
LEE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1801023718
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
55 FRUIT ST
Provider Second Line Business Mailing Address:
DEPARTMENT OF CT SURGERY, COX 6
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02114-2621
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-754-4410
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
740 S LIMESTONE STE J301
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEXINGTON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40536-2621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
859-323-1691
Provider Business Practice Location Address Fax Number:
859-323-1700
Provider Enumeration Date:
06/18/2009

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: 363LA2200X , with the licence number:  213890 , registered in the state of MA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2200X , with the licence number: 3007279 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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