Provider Demographics
NPI:1053098756
Name:GORDON, ERIKO MITO (STUDENT)
Entity type:Individual
Prefix:
First Name:ERIKO
Middle Name:MITO
Last Name:GORDON
Suffix:
Gender:F
Credentials:STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1417 CAROWINDS CIRCLE
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37803
Mailing Address - Country:US
Mailing Address - Phone:865-206-5032
Mailing Address - Fax:
Practice Address - Street 1:714 TIVERTON AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-8361
Practice Address - Country:US
Practice Address - Phone:865-206-5032
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-03
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program