Provider Demographics
NPI:1275601056
Name:MCGOURTY, MICHAEL ANTHONY (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:MCGOURTY
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 1:56 OAK ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:RI
Mailing Address - Zip Code:02842-4945
Mailing Address - Country:US
Mailing Address - Phone:401-829-2435
Mailing Address - Fax:
Practice Address - Street 1:93 THAMES ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:RI
Practice Address - Zip Code:02840-2536
Practice Address - Country:US
Practice Address - Phone:401-846-4150
Practice Address - Fax:401-846-9340
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2018-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA00221363AM0700X
RIPAC00221363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical