Healthcare Provider Details

I. General information

NPI: 1124610571
Provider Name (Legal Business Name): KARLI GORMLEY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/08/2021
Last Update Date: 02/08/2021
Certification Date: 02/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

261 N MAIN
CEDAR SPRINGS MI
49319-8041
US

IV. Provider business mailing address

PO BOX K221
CEDAR SPRINGS MI
49319-0921
US

V. Phone/Fax

Practice location:
  • Phone: 616-696-2020
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601010285
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: