Individual
KEVIN RAY GORDON
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
NP
Contact information
Practice address
8075 N SHADELAND AVE STE 330, INDIANAPOLIS, IN 46250-2694
(317) 355-7220
Mailing address
250 N SHADELAND AVE, INDIANAPOLIS, IN 46219-4959
Taxonomy
Speciality
Code
Description
License number
State
363LA2100X
Acute Care Nurse Practitioner
71011370A
IN
363LG0600X
Gerontology Nurse Practitioner
Primary
71011370A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000001567906
ANTHEM PTAN
IN
01
—
068010712
MEDICARE PTAN
IN
05
—
300053141
—
IN
01
—
Q00411112
RAILROAD PTAN
IN
Enumeration date
07/30/2021
Last updated
08/12/2025
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