Healthcare Provider Details

I. General information

NPI: 1164703153
Provider Name (Legal Business Name): CHARLES CHRISTOPHER GOSSMAN APRN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2011
Last Update Date: 10/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6055 N MAIN STREET RD
WEBB CITY MO
64870-7219
US

IV. Provider business mailing address

6055 N MAIN STREET RD
WEBB CITY MO
64870-7219
US

V. Phone/Fax

Practice location:
  • Phone: 417-206-0900
  • Fax: 417-206-0907
Mailing address:
  • Phone: 417-206-0900
  • Fax: 417-206-0907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number52-75482-121
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2014008349
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: