MEDICARE: CONRAD J GORMAN PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	8820	GA

General Provider Information

NPI Number	:	1033695408
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CONRAD J GORMAN PA-C

Provider Business Mailing Address
First Line	:	5505 ROSWELL RD STE 100
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30342-1983
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5505 ROSWELL RD STE 100
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30342-1983
Country	:	US
Telephone Number	:	404-480-9330
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/18/2018
Last Update Date	:	07/18/2018

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