Provider Demographics
NPI:1215306816
Name:GATEWAY PRIMARY CARE, LLC
Entity type:Organization
Organization Name:GATEWAY PRIMARY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:MCNULTY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-663-9410
Mailing Address - Street 1:3245 MOUNT MORIAH AVE
Mailing Address - Street 2:SUITE 9
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-7834
Mailing Address - Country:US
Mailing Address - Phone:270-683-2209
Mailing Address - Fax:270-926-8261
Practice Address - Street 1:3245 MOUNT MORIAH AVE
Practice Address - Street 2:SUITE 9
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-7834
Practice Address - Country:US
Practice Address - Phone:270-683-2209
Practice Address - Fax:270-926-8261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-24
Last Update Date:2017-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty