Basic Information
| Provider Information | |||||||||
| NPI: | 1639126162 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOMULKA | ||||||||
| FirstName: | KERRY | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NOETZEL | ||||||||
| OtherFirstName: | KERRY | ||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2 COATES DR | ||||||||
| Address2: | |||||||||
| City: | GOSHEN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109246758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8456511400 | ||||||||
| FaxNumber: | 8456511512 | ||||||||
| Practice Location | |||||||||
| Address1: | 30 HATFIELD LN | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | GOSHEN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109246766 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452942733 | ||||||||
| FaxNumber: | 8452946486 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2006 | ||||||||
| LastUpdateDate: | 09/26/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 010206-1 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.