MEDICARE: JESSICA GORMAN

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	163WP0200X	Pediatric Registered Nurse	708856	NY

General Provider Information

NPI Number	:	1043793599
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JESSICA GORMAN

Provider Business Mailing Address
First Line	:	159 HANCOCK DR
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13207-1544
Country	:	US
Telephone Number	:	315-382-5746
Fax Number	:

Provider Business Practice Location Address
First Line	:	228 LAFAYETTE RD
Second Line	:
City	:	SYRACUSE
State	:	NY
Zip	:	13205-2921
Country	:	US
Telephone Number	:	315-492-9990
Fax Number	:

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

Provider Enumeration Date	:	09/11/2018
Last Update Date	:	09/11/2018

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