Basic Information
| Provider Information | |||||||||
| NPI: | 1770121089 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOLL | ||||||||
| FirstName: | BRADLEY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1073 N HILTONHEAD WAY | ||||||||
| Address2: | |||||||||
| City: | EAGLE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836165460 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 810 JASMINE ST | ||||||||
| Address2: | |||||||||
| City: | OMAK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 988419578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098261760 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2019 | ||||||||
| LastUpdateDate: | 12/17/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/17/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 50150 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.