Basic Information
| Provider Information | |||||||||
| NPI: | 1710180906 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOSS | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | SUZANNE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1601 RIO GRANDE ST | ||||||||
| Address2: | SUITE 340 | ||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787011137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123248960 | ||||||||
| FaxNumber: | 5123248962 | ||||||||
| Practice Location | |||||||||
| Address1: | 1180 SETON PKWY | ||||||||
| Address2: | SUITE 340 | ||||||||
| City: | KYLE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786406178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5125040851 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2007 | ||||||||
| LastUpdateDate: | 01/28/2013 | ||||||||
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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 | 207V00000X | M4111 | TX | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 194598204 | 05 | TX | MEDICAID | 194598205 | 05 | TX | MEDICAID |