Provider Demographics
NPI:1053021733
Name:GORDON, TINA MARIE
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:GORDON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4657 E ODESSA DR
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85140-4516
Mailing Address - Country:US
Mailing Address - Phone:951-305-1462
Mailing Address - Fax:
Practice Address - Street 1:4657 E ODESSA DR
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85140-4516
Practice Address - Country:US
Practice Address - Phone:951-305-1462
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-02
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ88-07544070OtherIN HOME CARE FOR ELDERLY