Provider Demographics
NPI:1003169566
Name:GORNICK, FIONA KRISTINA (PT)
Entity Type:Individual
Prefix:
First Name:FIONA
Middle Name:KRISTINA
Last Name:GORNICK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 N WILLIAMS
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227
Mailing Address - Country:US
Mailing Address - Phone:503-288-2615
Mailing Address - Fax:503-288-0339
Practice Address - Street 1:1825 N WILLIAMS AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1864
Practice Address - Country:US
Practice Address - Phone:503-288-2615
Practice Address - Fax:503-288-0339
Is Sole Proprietor?:No
Enumeration Date:2012-10-22
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6914174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR237206Medicaid
OR237206Medicaid