Provider Demographics
NPI:1053368738
Name:GORTER, FORREST D (PAC)
Entity type:Individual
Prefix:
First Name:FORREST
Middle Name:D
Last Name:GORTER
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 S 12TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85034-2301
Mailing Address - Country:US
Mailing Address - Phone:602-495-5797
Mailing Address - Fax:
Practice Address - Street 1:1441 N 12TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2837
Practice Address - Country:US
Practice Address - Phone:602-747-4577
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant