Healthcare Provider Details

I. General information

NPI: 1821812322
Provider Name (Legal Business Name): MITCHELL GOSVENER PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2024
Last Update Date: 11/12/2024
Certification Date: 11/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 NEWPORT CENTER DR STE 503
NEWPORT BEACH CA
92660-7520
US

IV. Provider business mailing address

260 NEWPORT CENTER DR STE 503
NEWPORT BEACH CA
92660-7520
US

V. Phone/Fax

Practice location:
  • Phone: 714-334-5497
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberNP95032721
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: