Healthcare Provider Details

I. General information

NPI: 1265359459
Provider Name (Legal Business Name): MICHAEL GORE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 PAULARINO AVE STE D170
COSTA MESA CA
92626-3333
US

IV. Provider business mailing address

18 WILLOWOOD
ALISO VIEJO CA
92656-2972
US

V. Phone/Fax

Practice location:
  • Phone: 949-227-9102
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95040355
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: