=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356524862
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STASHA GOMINAK, MD, PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/07/2007
-----------------------------------------------------
Last Update Date | 09/28/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 OLYMPIC PLAZA CIR SUITE 912
-----------------------------------------------------
City | TYLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75701-1951
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-596-3808
-----------------------------------------------------
Fax | 903-596-3815
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 OLYMPIC PLAZA CIR 912
-----------------------------------------------------
City | TYLER
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75701-1951
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-596-3808
-----------------------------------------------------
Fax | 903-596-3815
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN
-----------------------------------------------------
Name | DR. STASHA C GOMINAK
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 903-596-3808
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084N0400X
-----------------------------------------------------
Taxonomy Name | Neurology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------