Healthcare Provider Details

I. General information

NPI: 1083632103
Provider Name (Legal Business Name): KATHRYN ANN GORMAN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 IRVING AVE
SYRACUSE NY
13210-2716
US

IV. Provider business mailing address

5105 BRIARLEDGE RD
SYRACUSE NY
13212-2626
US

V. Phone/Fax

Practice location:
  • Phone: 315-425-4031
  • Fax: 315-425-4861
Mailing address:
  • Phone: 315-425-4031
  • Fax: 315-425-4861

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number233852
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: