Provider Demographics
NPI:1205807286
Name:GORMAN, MARY (NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:GORMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:4967 CROOKS RD
Mailing Address - Street 2:STE. 130
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48098-5801
Mailing Address - Country:US
Mailing Address - Phone:248-952-1601
Mailing Address - Fax:248-952-0192
Practice Address - Street 1:4967 CROOKS RD STE 130
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48098-5812
Practice Address - Country:US
Practice Address - Phone:248-952-1601
Practice Address - Fax:734-402-0254
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4704079294363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
S79752Medicare UPIN