MEDICARE: DR. PAUL EDWARD GOURLEY D.O.

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	207P00000X	Emergency Medicine Physician	0102050040	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124015474
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PAUL EDWARD GOURLEY D.O.

Provider Business Mailing Address
First Line	:	15301 WARREN SHINGLE RD
Second Line	:
City	:	BEALE AFB
State	:	CA
Zip	:	95903-1907
Country	:	US
Telephone Number	:	530-634-4838
Fax Number	:

Provider Business Practice Location Address
First Line	:	15301 WARREN SHINGLE RD
Second Line	:
City	:	BEALE AFB
State	:	CA
Zip	:	95903-1907
Country	:	US
Telephone Number	:	530-634-4838
Fax Number	:

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

Provider Enumeration Date	:	10/03/2005
Last Update Date	:	07/07/2015

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