MEDICARE: NICOLE GOSS PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	2185587	TX

General Provider Information

NPI Number	:	1578425203
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE GOSS PTA

Provider Business Mailing Address
First Line	:	120 MEDINA ST
Second Line	:
City	:	SAN ANGELO
State	:	TX
Zip	:	76905-7728
Country	:	US
Telephone Number	:	402-910-9294
Fax Number	:

Provider Business Practice Location Address
First Line	:	1909 KNICKERBOCKER RD
Second Line	:
City	:	SAN ANGELO
State	:	TX
Zip	:	76904-5523
Country	:	US
Telephone Number	:	325-213-4420
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/01/2025
Last Update Date	:	12/01/2025

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