Individual
TRACEY GORDON
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
2827 NORTHGATE BOULEVARD, FORT WAYNE, IN 46835
(260) 492-1498
(260) 492-1614
Mailing address
2827 NORTHGATE BOULEVARD, FORT WAYNE, IN 46835
Taxonomy
Speciality
Code
Description
License number
State
225200000X
Physical Therapy Assistant
Primary
06004303A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1555656
—
IN
Enumeration date
08/29/2012
Last updated
08/29/2012
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