MEDICARE: DEANNA L GORTON RN

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	163WC0400X	Case Management Registered Nurse	369594	NY

General Provider Information

NPI Number	:	1386945046
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEANNA L GORTON RN

Provider Business Mailing Address
First Line	:	1968 GREENVILLE TPKE
Second Line	:
City	:	PORT JERVIS
State	:	NY
Zip	:	12771-3248
Country	:	US
Telephone Number	:	845-672-9322
Fax Number	:

Provider Business Practice Location Address
First Line	:	1968 GREENVILLE TPKE
Second Line	:
City	:	PORT JERVIS
State	:	NY
Zip	:	12771-3248
Country	:	US
Telephone Number	:	854-672-9322
Fax Number	:

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

Provider Enumeration Date	:	11/11/2010
Last Update Date	:	11/11/2010

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