Healthcare Provider Details

I. General information

NPI: 1366715625
Provider Name (Legal Business Name): JACK A. GOBLE JR. PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2012
Last Update Date: 03/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10755 FALLS RD SUITE 160
LUTHERVILLE MD
21093-4515
US

IV. Provider business mailing address

100 LEE ST
STEWARTSTOWN PA
17363-4061
US

V. Phone/Fax

Practice location:
  • Phone: 410-285-2777
  • Fax:
Mailing address:
  • Phone: 717-578-6660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA002128L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberC0001029
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: