Provider Demographics
NPI:1851400428
Name:O'GORMAN, JAYNE LYN (PA-C)
Entity type:Individual
Prefix:
First Name:JAYNE
Middle Name:LYN
Last Name:O'GORMAN
Suffix:
Gender:
Credentials:PA-C
Other - Prefix:
Other - First Name:JAYNE
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD, PA-C
Mailing Address - Street 1:200 NEW YORK AVE STE 150
Mailing Address - Street 2:
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-5227
Mailing Address - Country:US
Mailing Address - Phone:865-835-5855
Mailing Address - Fax:
Practice Address - Street 1:200 NEW YORK AVE STE 150
Practice Address - Street 2:
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-5227
Practice Address - Country:US
Practice Address - Phone:865-835-5855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007576-1363AM0700X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ36730Medicare UPIN