Healthcare Provider Details

I. General information

NPI: 1730148883
Provider Name (Legal Business Name): JOHN HUGH GOURLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2006
Last Update Date: 04/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 JARRETT WHITE RD TRIPLER ARMY MEDICAL CENTER ATTN: MCHK-QS
TRIPLER AMC HI
96859-5001
US

IV. Provider business mailing address

1220 HASE DR
HONOLULU HI
96819-2183
US

V. Phone/Fax

Practice location:
  • Phone: 808-433-2460
  • Fax: 808-433-1558
Mailing address:
  • Phone: 808-206-8572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number26NJ00106100
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: