Basic Information
| Provider Information | |||||||||
| NPI: | 1902090939 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GORSUCH | ||||||||
| FirstName: | KIMBERLY | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 680 N LAKE SHORE DR | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606114546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3126956868 | ||||||||
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| Practice Location | |||||||||
| Address1: | 259 E ERIE ST | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606112987 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129264475 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/04/2007 | ||||||||
| LastUpdateDate: | 11/14/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 19333 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.