Healthcare Provider Details

I. General information

NPI: 1235212424
Provider Name (Legal Business Name): WENDY JO GOSNELL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 06/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 MCNEEL LN
NORTH PLATTE NE
69101-6290
US

IV. Provider business mailing address

PO BOX 12855
BELFAST ME
04915-4019
US

V. Phone/Fax

Practice location:
  • Phone: 308-221-6262
  • Fax: 308-221-6261
Mailing address:
  • Phone: 617-402-1000
  • Fax: 888-864-4428

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number21972
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: