Provider Demographics
NPI:1114564630
Name:GOR, MITALIBEN RAJENDRAKUMAR (NP)
Entity Type:Individual
Prefix:
First Name:MITALIBEN
Middle Name:RAJENDRAKUMAR
Last Name:GOR
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 EDWARDS AVE
Mailing Address - Street 2:
Mailing Address - City:COOS BAY
Mailing Address - State:OR
Mailing Address - Zip Code:97420-3408
Mailing Address - Country:US
Mailing Address - Phone:541-404-1414
Mailing Address - Fax:
Practice Address - Street 1:1900 WOODLAND DR
Practice Address - Street 2:
Practice Address - City:COOS BAY
Practice Address - State:OR
Practice Address - Zip Code:97420-2099
Practice Address - Country:US
Practice Address - Phone:541-267-5151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-03
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201909528NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty