Provider Demographics
NPI:1912037201
Name:GORHAM, BECKY LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:BECKY
Middle Name:LYNN
Last Name:GORHAM
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:PO BOX 95590
Mailing Address - Street 2:
Mailing Address - City:SOUTH JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84095-0590
Mailing Address - Country:US
Mailing Address - Phone:801-352-9500
Mailing Address - Fax:
Practice Address - Street 1:19026 RIDGEWOOD PKWY STE 311
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78259-5502
Practice Address - Country:US
Practice Address - Phone:833-210-4673
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001731363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA10525OtherLICENSE
IL085001731OtherLICENSE
CAPA56173OtherLICENSE