Provider Demographics
NPI:1114961240
Name:GOURLEY, PETER GORDON (ARNP)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:GORDON
Last Name:GOURLEY
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2481 HALLEBERRY
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-8339
Mailing Address - Country:US
Mailing Address - Phone:509-989-7764
Mailing Address - Fax:509-764-5072
Practice Address - Street 1:1130 W PRAIRIE AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83815-8780
Practice Address - Country:US
Practice Address - Phone:208-209-0288
Practice Address - Fax:208-209-0289
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2016-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30005913363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health