MEDICARE: MR. MICHAEL GORE PA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	008532-1	NY

General Provider Information

NPI Number	:	1003823378
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MICHAEL GORE PA

Provider Business Mailing Address
First Line	:	482 TENNYSON DR
Second Line	:
City	:	STATEN ISLAND
State	:	NY
Zip	:	10312-6552
Country	:	US
Telephone Number	:	718-360-8607
Fax Number	:

Provider Business Practice Location Address
First Line	:	2818 OCEAN AVE
Second Line	:	SUITE #1
City	:	BROOKLYN
State	:	NY
Zip	:	11235-3170
Country	:	US
Telephone Number	:	718-934-8484
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/01/2006
Last Update Date	:	05/12/2009

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