Healthcare Provider Details

I. General information

NPI: 1275896102
Provider Name (Legal Business Name): AMANDA GOHLKE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2012
Last Update Date: 06/03/2023
Certification Date: 06/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 JOHNSTON WILLIS DR
NORTH CHESTERFIELD VA
23235-4730
US

IV. Provider business mailing address

PO BOX 980662 PATH: PATHOLOGY AP/CP
RICHMOND VA
23298-0662
US

V. Phone/Fax

Practice location:
  • Phone: 804-483-5155
  • Fax:
Mailing address:
  • Phone: 804-628-1690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberMT201300
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberD0085010
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: