Basic Information
| Provider Information | |||||||||
| NPI: | 1134758097 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORMAN | ||||||||
| FirstName: | NATHAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 N NINE MOUND RD | ||||||||
| Address2: | |||||||||
| City: | VERONA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535931032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088459531 | ||||||||
| FaxNumber: | 6088458684 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 N NINE MOUND RD | ||||||||
| Address2: | |||||||||
| City: | VERONA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535931032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088459531 | ||||||||
| FaxNumber: | 6088458684 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2020 | ||||||||
| LastUpdateDate: | 06/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 1134758097 | WI | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.