Provider Demographics
NPI:1073757795
Name:O'GORMAN, PHYLLIS (PT)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:
Last Name:O'GORMAN
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 1:1 UNIVERSITY OF NEW MEXICO
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87131-1511
Mailing Address - Country:US
Mailing Address - Phone:505-277-0111
Mailing Address - Fax:
Practice Address - Street 1:1 UNIVERSITY OF NEW MEXICO
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87131-1511
Practice Address - Country:US
Practice Address - Phone:505-277-0111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-24
Last Update Date:2014-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2253225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist