Provider Demographics
NPI:1518133123
Name:GORMAN, JACQUELINE A (PA-C)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:A
Last Name:GORMAN
Suffix:
Gender:F
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 1:7627 E 37TH ST N
Mailing Address - Street 2:APT #2001
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-2802
Mailing Address - Country:US
Mailing Address - Phone:316-641-5446
Mailing Address - Fax:
Practice Address - Street 1:9350 E 35TH ST N
Practice Address - Street 2:SUITE 101
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-2019
Practice Address - Country:US
Practice Address - Phone:316-265-1308
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-03
Last Update Date:2008-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-01133363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant