Provider Demographics
NPI:1053624015
Name:NURSE PRACTITIONER PROVIDER
Entity type:Organization
Organization Name:NURSE PRACTITIONER PROVIDER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:RHONJEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:RN-FNP-BC
Authorized Official - Phone:281-686-4469
Mailing Address - Street 1:16731 BETHAN GLEN LN
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77084-2651
Mailing Address - Country:US
Mailing Address - Phone:281-686-4469
Mailing Address - Fax:281-858-7618
Practice Address - Street 1:2626 S LOOP W
Practice Address - Street 2:350
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-2654
Practice Address - Country:US
Practice Address - Phone:713-334-1003
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-20
Last Update Date:2010-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX185033102Medicaid