Healthcare Provider Details

I. General information

NPI: 1407055742
Provider Name (Legal Business Name): SAN JUAN HEALTHCARE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2007
Last Update Date: 03/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

689 AIRPORT CENTER DR SUITE B
FRIDAY HARBOR WA
98250
US

IV. Provider business mailing address

PO BOX 1550
FRIDAY HARBOR WA
98250-1550
US

V. Phone/Fax

Practice location:
  • Phone: 360-378-1338
  • Fax: 360-378-8130
Mailing address:
  • Phone: 360-378-1338
  • Fax: 360-378-1830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JOHN BURK GOSSOM
Title or Position: OWNER
Credential: MD
Phone: 360-378-1338