Basic Information
| Provider Information | |||||||||
| NPI: | 1720218050 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOUGE | ||||||||
| FirstName: | JERRY | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 BURTON HILLS BLVD | ||||||||
| Address2: | STE 175 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372156403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6159882014 | ||||||||
| FaxNumber: | 6152081303 | ||||||||
| Practice Location | |||||||||
| Address1: | 2018 WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379215718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655440406 | ||||||||
| FaxNumber: | 8655440480 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2009 | ||||||||
| LastUpdateDate: | 12/29/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 1728 | TN | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 363A00000X | 1728 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1515542 | 05 | TN | MEDICAID |