Healthcare Provider Details

I. General information

NPI: 1902311319
Provider Name (Legal Business Name): LEE J GOTTHARDT FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2017
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12655 WARWICK BLVD STE B
NEWPORT NEWS VA
23606-2501
US

IV. Provider business mailing address

860 OMNI BLVD STE 401
NEWPORT NEWS VA
23606-4430
US

V. Phone/Fax

Practice location:
  • Phone: 757-595-3570
  • Fax: 757-592-9280
Mailing address:
  • Phone: 757-232-8860
  • Fax: 757-232-8875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024175673
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: