Provider Demographics
NPI:1932177631
Name:GORHAM, SARA (CNM,CRNP)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:
Last Name:GORHAM
Suffix:
Gender:F
Credentials:CNM,CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 SARATOGA RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GANSEVOORT
Mailing Address - State:NY
Mailing Address - Zip Code:12831-1599
Mailing Address - Country:US
Mailing Address - Phone:518-363-8815
Mailing Address - Fax:518-363-8831
Practice Address - Street 1:665 SARATOGA RD
Practice Address - Street 2:SUITE 100
Practice Address - City:GANSEVOORT
Practice Address - State:NY
Practice Address - Zip Code:12831-1599
Practice Address - Country:US
Practice Address - Phone:518-363-8815
Practice Address - Fax:518-363-8831
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2024-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY421238363LW0102X
NY001706367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
581397572OtherTAX ID #
GA417108236AMedicaid