Provider Demographics
NPI:1285833525
Name:GORTON, JAMIE (RN)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:GORTON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7492 BIG TREE RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:NY
Mailing Address - Zip Code:14487-9509
Mailing Address - Country:US
Mailing Address - Phone:585-367-8522
Mailing Address - Fax:
Practice Address - Street 1:7492 BIG TREE RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:NY
Practice Address - Zip Code:14487-9509
Practice Address - Country:US
Practice Address - Phone:585-367-8522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-17
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY543107-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02495765Medicaid