Provider Demographics
NPI:1063135515
Name:GORE, BRANDON
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:GORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 CABEZON BLVD SE STE 102
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-1513
Mailing Address - Country:US
Mailing Address - Phone:505-994-2599
Mailing Address - Fax:
Practice Address - Street 1:2401 CABEZON BLVD SE STE 102
Practice Address - Street 2:
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-1513
Practice Address - Country:US
Practice Address - Phone:505-994-2599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMA-1326225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant