Provider Demographics
NPI:1144218595
Name:GORE, LINDA S (PA)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:S
Last Name:GORE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1345 PLAZA CT N STE 1A
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-2832
Mailing Address - Country:US
Mailing Address - Phone:303-665-3036
Mailing Address - Fax:
Practice Address - Street 1:2525 13TH STREET
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-4104
Practice Address - Country:US
Practice Address - Phone:303-449-6050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-10
Last Update Date:2013-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO98363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO51804221Medicaid