Basic Information
| Provider Information | |||||||||
| NPI: | 1114961240 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOURLEY | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | GORDON | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2481 HALLEBERRY | ||||||||
| Address2: | |||||||||
| City: | HAYDEN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838358339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5099897764 | ||||||||
| FaxNumber: | 5097645072 | ||||||||
| Practice Location | |||||||||
| Address1: | 1130 W PRAIRIE AVE | ||||||||
| Address2: | |||||||||
| City: | COEUR D ALENE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838158780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082090288 | ||||||||
| FaxNumber: | 2082090289 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 02/11/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | AP30005913 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.