Provider Demographics
NPI:1033593801
Name:GORE, KENNETH R (CRNA)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:R
Last Name:GORE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 RED CAMELLA DR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-3963
Mailing Address - Country:US
Mailing Address - Phone:512-948-0850
Mailing Address - Fax:
Practice Address - Street 1:711 W 38TH ST STE E4
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1132
Practice Address - Country:US
Practice Address - Phone:512-768-0652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-11
Last Update Date:2025-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX672092367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered