Healthcare Provider Details

I. General information

NPI: 1275596488
Provider Name (Legal Business Name): JOHN JOSEPH GOSS JR. RN
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8106 W LAPHAM ST
WEST ALLIS WI
53214-4442
US

IV. Provider business mailing address

21505 S KOSKI PARK LN
CHENEY WA
99004-7953
US

V. Phone/Fax

Practice location:
  • Phone: 414-380-1411
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number163WH0200X
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: