Basic Information
| Provider Information | |||||||||
| NPI: | 1003920380 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOSCH | ||||||||
| FirstName: | NORMAN | ||||||||
| MiddleName: | ALBERT | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7902 56TH STREET CT W | ||||||||
| Address2: | |||||||||
| City: | UNIVERSITY PLACE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 984675904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2535660460 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 17TH AND C ST. | ||||||||
| Address2: | BLDG. 11582 | ||||||||
| City: | FORT LEWIS | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2539661991 | ||||||||
| FaxNumber: | 2539672639 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171000000X | MD00022390 | WA | Y | Other Service Providers | Military Health Care Provider |
ID Information
| ID | Type | State | Issuer | Description | VAD000 | 05 | WA | MEDICAID |