Provider Demographics
NPI:1154941029
Name:GORE, BALFOUR ANTHONY
Entity type:Individual
Prefix:MR
First Name:BALFOUR
Middle Name:ANTHONY
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 1:1206 RIVER RD APT 2
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19809-2402
Mailing Address - Country:US
Mailing Address - Phone:302-384-1462
Mailing Address - Fax:
Practice Address - Street 1:100 ROCKFORD DR
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2120
Practice Address - Country:US
Practice Address - Phone:302-996-5480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-21
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEL8-0000205363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty