Provider Demographics
NPI:1629470265
Name:GORRELL, MATTISON (PA)
Entity Type:Individual
Prefix:MISS
First Name:MATTISON
Middle Name:
Last Name:GORRELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MATTISON
Other - Middle Name:
Other - Last Name:GORRELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:535 MAIN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:OLEAN
Mailing Address - State:NY
Mailing Address - Zip Code:14760-1593
Mailing Address - Country:US
Mailing Address - Phone:716-376-2258
Mailing Address - Fax:716-376-2340
Practice Address - Street 1:535 MAIN ST
Practice Address - Street 2:
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760-1500
Practice Address - Country:US
Practice Address - Phone:716-376-2258
Practice Address - Fax:716-376-2340
Is Sole Proprietor?:No
Enumeration Date:2014-09-25
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021523363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant