Provider Demographics
NPI:1417916024
Name:GORSLINE, MICHAEL D (PAC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:D
Last Name:GORSLINE
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 GUTHRIE SQ
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-888-5858
Mailing Address - Fax:
Practice Address - Street 1:1 GUTHRIE SQ
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840-1625
Practice Address - Country:US
Practice Address - Phone:570-888-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA052217363A00000X
NY011058-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAGU039978OtherMEDICARE GROUP
NY02728614Medicaid
PACC9269OtherRR MEDICARE GROUP
PAP00304998OtherRR MEDICARE PIN
Q60555Medicare UPIN
PA097168N9SMedicare ID - Type Unspecified