Healthcare Provider Details

I. General information

NPI: 1639126162
Provider Name (Legal Business Name): KERRY GOMULKA PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KERRY NOETZEL PA

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 09/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 HATFIELD LN SUITE 101
GOSHEN NY
10924-6766
US

IV. Provider business mailing address

2 COATES DR
GOSHEN NY
10924-6758
US

V. Phone/Fax

Practice location:
  • Phone: 845-294-2733
  • Fax: 845-294-6486
Mailing address:
  • Phone: 845-651-1400
  • Fax: 845-651-1512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number010206-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: