Basic Information
| Provider Information | |||||||||
| NPI: | 1700929296 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORE | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | ANITA | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | P.A.-C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3001 EXECUTIVE DR STE 130 | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337625323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273470005 | ||||||||
| FaxNumber: | 7275416558 | ||||||||
| Practice Location | |||||||||
| Address1: | 2919 W SWANN AVE STE 106 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336094049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139302829 | ||||||||
| FaxNumber: | 8139309522 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2007 | ||||||||
| LastUpdateDate: | 09/28/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA0002625 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.