Provider Demographics
NPI:1619638186
Name:GORMAN, ELJIN JON (MS LAT ATC)
Entity Type:Individual
Prefix:
First Name:ELJIN
Middle Name:JON
Last Name:GORMAN
Suffix:
Gender:M
Credentials:MS LAT ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2004 STONE PL
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-8667
Mailing Address - Country:US
Mailing Address - Phone:505-903-1661
Mailing Address - Fax:
Practice Address - Street 1:2004 STONE PL
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:NM
Practice Address - Zip Code:88101-8667
Practice Address - Country:US
Practice Address - Phone:505-903-1661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-06
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMAT7122255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer