Provider Demographics
NPI:1861147621
Name:GORSHKOVA, IRINA
Entity type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:GORSHKOVA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 E NIZHONI BLVD
Mailing Address - Street 2:
Mailing Address - City:GALLUP
Mailing Address - State:NM
Mailing Address - Zip Code:87301-5757
Mailing Address - Country:US
Mailing Address - Phone:505-722-6603
Mailing Address - Fax:
Practice Address - Street 1:517 E NIZHONI BLVD
Practice Address - Street 2:
Practice Address - City:GALLUP
Practice Address - State:NM
Practice Address - Zip Code:87301-5757
Practice Address - Country:US
Practice Address - Phone:505-722-6603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-19
Last Update Date:2022-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2022-0114363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty