Healthcare Provider Details

I. General information

NPI: 1578087169
Provider Name (Legal Business Name): JAMES GOOSS FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 WEST KANSAS AVENUE
JAL NM
88252
US

IV. Provider business mailing address

PO BOX Z
JAL NM
88252-2525
US

V. Phone/Fax

Practice location:
  • Phone: 575-395-3400
  • Fax: 575-395-2781
Mailing address:
  • Phone: 575-395-3400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP-03305
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: