Basic Information
| Provider Information | |||||||||
| NPI: | 1932123106 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GORMAN | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MORRISSEY | ||||||||
| OtherFirstName: | TIFFANY | ||||||||
| OtherMiddleName: | GORMAN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 221 E HACIENDA AVE | ||||||||
| Address2: | STE B | ||||||||
| City: | CAMPBELL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950086616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4083763350 | ||||||||
| FaxNumber: | 4083744130 | ||||||||
| Practice Location | |||||||||
| Address1: | 221 E HACIENDA AVE | ||||||||
| Address2: | STE B | ||||||||
| City: | CAMPBELL | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4083763350 | ||||||||
| FaxNumber: | 4083744130 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 08/21/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | A061360 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
No ID Information.