Healthcare Provider Details

I. General information

NPI: 1720218050
Provider Name (Legal Business Name): JERRY K GOUGE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2009
Last Update Date: 12/29/2021
Certification Date: 12/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2018 WESTERN AVE
KNOXVILLE TN
37921-5718
US

IV. Provider business mailing address

30 BURTON HILLS BLVD STE 175
NASHVILLE TN
37215-6403
US

V. Phone/Fax

Practice location:
  • Phone: 865-544-0406
  • Fax: 865-544-0480
Mailing address:
  • Phone: 615-988-2014
  • Fax: 615-208-1303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number1728
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1728
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: