Basic Information
| Provider Information | |||||||||
| NPI: | 1861976904 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORMAN | ||||||||
| FirstName: | BRITNEY | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4200 DAHLBERG DR STE 300 | ||||||||
| Address2: | |||||||||
| City: | GOLDEN VALLEY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554224841 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9525125600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11225 ULYSSES ST NE | ||||||||
| Address2: | |||||||||
| City: | BLAINE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554344261 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7633022600 | ||||||||
| FaxNumber: | 7633022601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2018 | ||||||||
| LastUpdateDate: | 01/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085-006752 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 13349 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.