Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LA2200X | Nurse Practitioner - Adult Health | 201609181NP | OR |
N | 363LA2200X | Nurse Practitioner - Adult Health | 21035 | CA |
NPI | 1023316452 |
---|---|
Provider Name | Mr. Colin A. Gershon |
First Address | Portland, OR 97239-3011 |
Second Address | Portland, OR 97239-3011 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 09/03/2011 |
Last Update Date | 22/05/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
060012 | (05) | AZ |