MEDICARE: MISS KIMBERLY ANITA GORE P.A.-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	363AM0700X	Medical Physician Assistant	PA0002625	FL
2	363A00000X	Physician Assistant	PA2625	FL

General Provider Information

NPI Number	:	1700929296
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS KIMBERLY ANITA GORE P.A.-C.

Provider Business Mailing Address
First Line	:	30115 COUNTY ROAD 52 STE 101
Second Line	:
City	:	SAN ANTONIO
State	:	FL
Zip	:	33576-8243
Country	:	US
Telephone Number	:	813-467-4244
Fax Number	:

Provider Business Practice Location Address
First Line	:	30115 COUNTY ROAD 52 STE 101
Second Line	:
City	:	SAN ANTONIO
State	:	FL
Zip	:	33576-8243
Country	:	US
Telephone Number	:	813-467-4244
Fax Number	:

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

Provider Enumeration Date	:	02/14/2007
Last Update Date	:	03/08/2024

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