Provider Demographics
NPI:1992157176
Name:GORGONE, TERYN (NP)
Entity type:Individual
Prefix:MRS
First Name:TERYN
Middle Name:
Last Name:GORGONE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 YORK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-5663
Mailing Address - Country:US
Mailing Address - Phone:646-962-2764
Mailing Address - Fax:
Practice Address - Street 1:130 2ND AVE
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451-1100
Practice Address - Country:US
Practice Address - Phone:888-300-2483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-12
Last Update Date:2018-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2261348207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine