Healthcare Provider Details

I. General information

NPI: 1548267560
Provider Name (Legal Business Name): GEORGE T GOUCHER PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 07/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1718 E KESSLER BLVD
LONGVIEW WA
98632-1842
US

IV. Provider business mailing address

PO BOX 3002
LONGVIEW WA
98632-0302
US

V. Phone/Fax

Practice location:
  • Phone: 360-747-5800
  • Fax: 360-575-3846
Mailing address:
  • Phone: 360-747-5800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA10002266
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: