MEDICARE: MR. CHARLES CHRISTOPHER GOSSMAN APRN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	52-75482-121	KS
2	363LF0000X	Family Nurse Practitioner	2014008349	MO

General Provider Information

NPI Number	:	1164703153
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CHARLES CHRISTOPHER GOSSMAN APRN

Provider Business Mailing Address
First Line	:	6055 N MAIN STREET RD
Second Line	:
City	:	WEBB CITY
State	:	MO
Zip	:	64870-7219
Country	:	US
Telephone Number	:	417-206-0900
Fax Number	:	417-206-0907

Provider Business Practice Location Address
First Line	:	6055 N MAIN STREET RD
Second Line	:
City	:	WEBB CITY
State	:	MO
Zip	:	64870-7219
Country	:	US
Telephone Number	:	417-206-0900
Fax Number	:	417-206-0907

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/02/2011
Last Update Date	:	10/03/2015

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