Provider Demographics
NPI:1255898102
Name:GORDON, RONALD GLEN (APRN, FNP-BC)
Entity type:Individual
Prefix:
First Name:RONALD
Middle Name:GLEN
Last Name:GORDON
Suffix:
Gender:M
Credentials:APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2572 DIANE AVE SE
Mailing Address - Street 2:
Mailing Address - City:PALM BAY
Mailing Address - State:FL
Mailing Address - Zip Code:32909-6448
Mailing Address - Country:US
Mailing Address - Phone:321-537-0298
Mailing Address - Fax:
Practice Address - Street 1:250 N WICKHAM RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-8625
Practice Address - Country:US
Practice Address - Phone:321-752-1491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-27
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11000215363LF0000X
FLRN9181705163WW0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WW0000XNursing Service ProvidersRegistered NurseWound Care