MEDICARE: STACEY GORE PTA

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	225200000X	Physical Therapy Assistant	A2938	NC

General Provider Information

NPI Number	:	1770971699
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY GORE PTA

Provider Business Mailing Address
First Line	:	251 MARSH HAVEN DR
Second Line	:
City	:	SNEADS FERRY
State	:	NC
Zip	:	28460-7549
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	26 OFFICE PARK DR
Second Line	:
City	:	JACKSONVILLE
State	:	NC
Zip	:	28546-7325
Country	:	US
Telephone Number	:	910-577-3355
Fax Number	:

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

Provider Enumeration Date	:	12/30/2014
Last Update Date	:	03/16/2026

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