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General NPI Number Information
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NPI Number | 1386807030
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Entity Type | Individual
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Provider Name | IVAN ROBERT GOSSAGE NP
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Gender | Male
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Dates
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Enumeration Date | 07/02/2008
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Last Update Date | 10/12/2021
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Provider Practice Location Address
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Address Line | 1660 HUMBOLDT RD STE 3
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City | CHICO
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State | CA
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Zip | 95928-9199
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Country | US
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Telephone | 530-530-3370
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Fax |
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Provider Business Mailing Address
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Address Line | 1660 HUMBOLDT RD STE 3
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City | CHICO
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State | CA
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Zip | 95928-9199
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Country | US
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Telephone | 530-899-3370
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 95014269
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 163WP0808X
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Taxonomy Name | Psychiatric/Mental Health Registered Nurse
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License Number | 808252
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 164X00000X
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Taxonomy Name | Licensed Vocational Nurse
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License Number | 231037
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License Number State | CA
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