Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | CH9576 | FL |
N | 111N00000X | Chiropractor | CHIR008143 | GA |
N | 111NR0400X | Rehabilitation Chiropractor | CHIR008143 | GA |
NPI | 1003952573 |
---|---|
Provider Name | Dr. Wayne Gordon |
First Address | Ponte Vedra Beach, FL 32082-6613 |
Second Address | Ponte Vedra Beach, FL 32082-6613 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/01/2007 |
Last Update Date | 26/01/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
V11698 | (02) | GA |