Provider Demographics
NPI:1205942844
Name:GORE, ANGELA P (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MRS
First Name:ANGELA
Middle Name:P
Last Name:GORE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:192 STILLEY RD
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-5933
Mailing Address - Country:US
Mailing Address - Phone:318-484-3401
Mailing Address - Fax:318-484-3402
Practice Address - Street 1:501 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 3A
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-8124
Practice Address - Country:US
Practice Address - Phone:318-484-3899
Practice Address - Fax:318-484-3887
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA71598APO4777363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1454877Medicaid