Provider Demographics
NPI:1164543336
Name:GORGONI, BRIAN M (PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:M
Last Name:GORGONI
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HYGEIA DR STE 2300
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2049
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4755 OGLETOWN STANTON RD STE 2670
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19718-0002
Practice Address - Country:US
Practice Address - Phone:302-733-2438
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2019-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC5-0000121363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant