Healthcare Provider Details

I. General information

NPI: 1083601850
Provider Name (Legal Business Name): PAUL P GORMAN A.T.,C. ; P.T.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/05/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

533 W COLUMBIA ST
EVANSVILLE IN
47710-1617
US

IV. Provider business mailing address

9400 SLATE RD
EVANSVILLE IN
47720-8002
US

V. Phone/Fax

Practice location:
  • Phone: 812-759-3001
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36000651A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: