Provider Demographics
NPI:1003823378
Name:GORE, MICHAEL (PA)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:GORE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:482 TENNYSON DR
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-6552
Mailing Address - Country:US
Mailing Address - Phone:718-360-8607
Mailing Address - Fax:
Practice Address - Street 1:2818 OCEAN AVE
Practice Address - Street 2:SUITE #1
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-3170
Practice Address - Country:US
Practice Address - Phone:718-934-8484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2009-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008532-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant