Basic Information
| Provider Information | |||||||||
| NPI: | 1356342364 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORMAN | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | JUSTIN | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1301 BERTHA HOWE AVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | MESQUITE | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890277502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023460800 | ||||||||
| FaxNumber: | 7023460801 | ||||||||
| Practice Location | |||||||||
| Address1: | 1301 BERTHA HOWE AVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | MESQUITE | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890277502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7023460800 | ||||||||
| FaxNumber: | 7023460801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2005 | ||||||||
| LastUpdateDate: | 01/16/2013 | ||||||||
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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 | 207Q00000X | 38165 | CO | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | DO1423 | NV | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.