Healthcare Provider Details

I. General information

NPI: 1245221886
Provider Name (Legal Business Name): JOHN BURK GOSSOM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2005
Last Update Date: 03/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

689 AIRPORT CENTER DR STE 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: 360-378-1830
Mailing address:
  • Phone: 360-378-1338
  • Fax: 360-378-1830

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberMD00018422
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: