Provider Demographics
NPI:1174249981
Name:GORGUS, KATLYN
Entity type:Individual
Prefix:
First Name:KATLYN
Middle Name:
Last Name:GORGUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 2ND ST NE
Mailing Address - Street 2:
Mailing Address - City:ARAB
Mailing Address - State:AL
Mailing Address - Zip Code:35016-5411
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:42D MEDICAL GROUP
Practice Address - Street 2:300 S. TWINING ST., BLDG 760
Practice Address - City:MAXWELL AFB
Practice Address - State:AL
Practice Address - Zip Code:36112-6027
Practice Address - Country:US
Practice Address - Phone:580-481-7082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-13
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians