Healthcare Provider Details

I. General information

NPI: 1184550097
Provider Name (Legal Business Name): MATTHEW RYAN GORMAN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2026
Last Update Date: 06/18/2026
Certification Date: 06/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

405 W COUNTRY CLUB RD
ROSWELL NM
88201-5209
US

IV. Provider business mailing address

388 HAYES RIDGE RD
INDIAN MOUND TN
37079-5217
US

V. Phone/Fax

Practice location:
  • Phone: 575-622-8170
  • Fax:
Mailing address:
  • Phone: 575-622-8170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2026-0065
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: