Provider Demographics
NPI:1174961940
Name:GORE, MARCIE (PA-C)
Entity type:Individual
Prefix:
First Name:MARCIE
Middle Name:
Last Name:GORE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARCIE
Other - Middle Name:
Other - Last Name:CRANDALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:12150 30 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48095-2035
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12150 30 MILE RD
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MI
Practice Address - Zip Code:48095-2035
Practice Address - Country:US
Practice Address - Phone:586-752-7256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-13
Last Update Date:2015-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601006695363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant