Provider Demographics
NPI:1467236729
Name:GORE, NICHOLAS (PA-C)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:GORE
Suffix:
Gender:M
Credentials:PA-C
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Other - Credentials:
Mailing Address - Street 1:4540 N WILSON DR APT 2
Mailing Address - Street 2:
Mailing Address - City:SHOREWOOD
Mailing Address - State:WI
Mailing Address - Zip Code:53211-1347
Mailing Address - Country:US
Mailing Address - Phone:715-571-7743
Mailing Address - Fax:
Practice Address - Street 1:10625 W NORTH AVE STE 101B
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-2315
Practice Address - Country:US
Practice Address - Phone:414-877-5350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-18
Last Update Date:2023-08-18
Deactivation Date:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant