Provider Demographics
NPI:1619536844
Name:GORMAN, LISA M (FNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:GORMAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:200 S PARK RD STE 200
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33021-8541
Mailing Address - Country:US
Mailing Address - Phone:954-607-9826
Mailing Address - Fax:954-923-1299
Practice Address - Street 1:6240 N DURANGO DR STE 120
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89149-3916
Practice Address - Country:US
Practice Address - Phone:954-923-7440
Practice Address - Fax:954-923-1299
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-11
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NV818245363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty