=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801651815
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID GOSSARD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/19/2024
-----------------------------------------------------
Last Update Date | 02/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1284 LEASBURG RD
-----------------------------------------------------
City | ROXBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27574-8485
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-860-6157
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 251 MCKINLEY RD
-----------------------------------------------------
City | TOPPENISH
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98948-9518
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | 32798
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225200000X
-----------------------------------------------------
Taxonomy Name | Physical Therapy Assistant
-----------------------------------------------------
License Number | CP029440A
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------