Active NPI
Tracey Gordon
- Physical Therapy Assistant
- Fort Wayne, IN
National Provider Identifier
1801144464
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Physical Therapy Assistant
- License
- 06004303A
- Practice address
- 2827 Northgate Boulevard
Fort Wayne, IN 46835 - Phone
- (260) 492-1498
- Fax
- (260) 492-1614
- NPI assigned
- Aug 29, 2012
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Physical Therapy Assistant | 225200000X | 06004303A | IN | Primary |
Addresses
Primary practice location
2827 Northgate Boulevard
Fort Wayne, IN 46835
Mailing address
2827 Northgate Boulevard
Fort Wayne, IN 46835
Other identifiers 1
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1555656 | Medicaid | IN |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 06004303A | IN | MD | Physical Therapy Assistant |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1346198400000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1346198400000",
"number": "1801144464",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2827 NORTHGATE BOULEVARD",
"city": "FORT WAYNE",
"state": "IN",
"postal_code": "46835"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2827 NORTHGATE BOULEVARD",
"city": "FORT WAYNE",
"state": "IN",
"postal_code": "46835",
"telephone_number": "260-492-1498",
"fax_number": "260-492-1614"
}
],
"practiceLocations": [],
"basic": {
"last_name": "GORDON",
"first_name": "TRACEY",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2012-08-29",
"last_updated": "2012-08-29",
"status": "A"
},
"taxonomies": [
{
"code": "225200000X",
"taxonomy_group": "",
"desc": "Physical Therapy Assistant",
"state": "IN",
"license": "06004303A",
"primary": true
}
],
"identifiers": [
{
"code": "05",
"desc": "MEDICAID",
"issuer": null,
"identifier": "1555656",
"state": "IN"
}
],
"endpoints": [],
"other_names": []
}Other providers in Fort Wayne, IN
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 29, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.